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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Properiy Owner Name: <br />Installation Address: <br />Cily: �J`Z''�1- "� Slale: I �1l� v Zip: /� .c7� <br />Mailing Address (il diNerentJ: <br />City: <br />Finail: <br />State: <br />Phone: ( <br />l olal Cost lo Install Device (from contractorinwice): $ ���•� . r5 tS <br />Pleasc verify tha following: <br />� I am the owner of the property where Ihe baekwater prevenlion device was installed. <br />�I worked with thc coNractor lo delermine the location for the backwater prevention device and <br />understand Ihat Ihe decision regarding Ihe localion ol the device was mine. <br />� My contractor instrucled me how lo access, inspect, and maintain the device. <br />�I understand lhat I am responsible for maintaining the backwaler prevenlion device and keeping <br />d in yood working order, uNess it is insiallcd in lhe city rigM•of-way. <br />,�-] Ii I sell my properly, I will make potenlial buyr.rs aware o(the backwater prevenlion device and <br />lhe need to inspecl and maintain il on e regular basis. <br />�( I am enclosing all of ihe necessary paperwoik (use Ihe yellow Rebate Submil�ai Checklisl). <br />Setuct from the tollawing: <br />�The coNraclor identiGed downspouls or olher drainage Ilines that were connected lo my sewer <br />line (between my housc and thc installed device) and removed, or rorouted them. <br />J� io my knowtedc�e, my property has no downspouls or olher drainage connected lo my sewer line <br />(befween my house and the inslalled device). <br />��'j There are downspouls or other drainage lines connecled lo my sewer line (belween my liouse <br />� and the inslalled device). 1 understand thal Ieaving these conneclions r.reates a risk o(1looding <br />and I accepl that nsk. <br />Signaturc Date ('? '��� <br />