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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Pr�perty Owner Name: <br />��:stallation Address: <br />i <br />Ciry: �veiG� 5tate W/�- z+p: 9 frlv 3 <br />s <br />Mailing Address (ildillerenQ: �534 /V. �p�l ,�� <br />City: .��wY1/G State: �/✓� z�p: 9 8i33 <br />Email: �� d:�uA (�i ofvw�: �• Co �^^ Phone: �,��) 33G" 89 d� <br />� : <br />Total Cosl to Install Device (Irom confractorinvoice): S �5�� � <br />Please verify the following: <br />�� 1 am the owner of the property where the backv;ater prevenlion device �vas installed. <br />1 worked with the contractor lo determine the location for the backwater prevention device �nd <br />understand Ihal Ihe decision regarding the location of the device was mine. <br />� My contractor instruc�ed me how lo access, inspect, and maintain the device. <br />I understand ihal I am responsible for rr�aintainin� the backwater prevention device and keeping <br />it in good working order, unless it is installed in the ciry right-of-way. <br />�I( I sell my proporty, I will make polential buyers aware of the back�vater prevention devico and <br />the need to inspect and mainlain it on a regular basis. <br />� I am enclosing all oi the necessary papenvork (use the yellow Rebate Submiltal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Ilines that were connected to my se�ver <br />line (behveen my house and Ihe installed device) and removed, or rerouled lhem. <br />To my knowledge, my property has no downspouts or olher drainage connecled lo my sewer line <br />(betwecn my house and Ihe inslalled device). <br />❑ There are downspouls or other drainage lines connecled to my sewer line (6elween my house <br />and ihe installed device). I understand that leaving these connections creates a risk of flooding <br />and I acce�bthat risk. <br />Date "�' /G % f <br />