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`� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ovmer Name: 5 o Ur � -� �,,.z , L <br />Installalion Address: S S ti� C�� �.s y' i�vr <br />Cily: C-`(. c•n.F u Stale: w// Zip: � n�-° 3 <br />Mailing Address (ildiHerent): <br />City: <br />Email: <br />� <br />State: <br />Phone: ( <br />Tolal Cosl lo Inslall Device (Irom coMraclor invoice): 5 Z`i �' %� <br />Please verify the following: <br />� I am the owner of the pwperty where the backv�ater prevenlion device was installed. <br />[�?,'J I worked ti�ilh the contrar.tor to determine the bcation for Ihe 6ackv�ater prevention device and <br />`understand that the decision regarding the location nf the device was mine. <br />j�J My contraci�r i�; �r: �cled me how to access, inspect, and maintain thc device. <br />[� I understand lhat I am responsible for maintaining lhe backwaler prevention device and keeping <br />it m good working order, unless it is installed in the city right-of-way. <br />�] If I sell my propeAy, I will make potential buyers aware o( Ihe backwa�er prevenlion.device and <br />'\ the need lo insped and maintain it on a regular basis. <br />[�j I am enclosing all of fhe necessary papen�aork (use lhe yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The conlractor idenlified do�vnspouls or olher drainage Ilines Ihal �vere connecled to my sewer <br />line (between my house and the inslalled dev!ce) and removed, or rerouted them. <br />[� To my knowledge, my property has no downspouls or other drainage cennected to my sewer line <br />(behveen my house and Ihe installed device). <br />❑ There are dotvnspouls or other drainage lines connected to my sewer line (behveen my house <br />and the installed device). I undcrslend thal leaving these mnnectlons rrnates a rlsk of tloodin� <br />and I accept lhat risk. <br />Signature /�".`-�4 S /�L�-�'C Date 1--i-� <br />