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�/ <br />� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: cC�l�t��[ a��' <br />Inslallation Address: � / ��'�� -`" ' <br />City: _�1.�-P.l�'�� __ State: VV %� . Zip:�.� 3 <br />Mailing Address (if different): _�7��_ . �/ � � '��" <br />City: _��Y �c�y �t / Stale: �j% ht . _ Z�P�--L�� � -- <br />Email:. �l `SQ _Q������e� (4'--� a(O-�(371 <br />Tolai Cost lo Install Device (from confractor invoiceJ: $� L� V v <br />Piease verify the following: <br />� m the ovaner of lhe property where lhe backwater prevenlion device was installed. <br />��w ed wilh the conlractor to delermine lhe localion (or Uie backwaler prevenlion device and <br />i dcrstand lhal lhe decision regarding the localion of the device was mine. <br />,[� My contractor instrucled me how lo access, inspect, and mainlain lhe device. <br />�iinderstand lhal I am responsible for maintaining the backwater prevention device and keeping <br />i m good working order, unless it is installed in the ciry �ight-of-way. <br />If I scll my property, I will make potential buyers aware of the backwater prevenlion deyice and <br />the need to inspect and mainlain it on a regular basis. <br />� 1 am enclosing �II of the necessary paperv�ork (use the yellow Rebate Submittal Checklist). <br />Select from thc following: <br />❑ The conlraclor idenli(ied downspouts or other drainage Ilines thal were connecled to my sewer <br />line (belv�een my house and the installed devicc) and removed, or rerouled Ihem. <br />L�o my knowledge, my properry has no downspouts or other drainage connecled lo my suwer line <br />(belwr.en my house and lhe inslalled device). <br />�] There are downspouts or olher drainaye lines connecled to my sewer linc (between my house <br />and the inslalled device). I undersland that leaving these connections creales a dsk of (looding <br />and I accepl thal risk. <br />Signature���� ���'� Date U�'��� <br />