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� <br />� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Propetty Owner Name: <br />Installation Address: <br />c��Y: Cv�r�-��' <br />�' qSao� <br />State:� Zip: <br />Mailing Address (if diNerenfJ: _ � <br />Cily: <br />State; <br />Emaii: �j(�IOu1I��Lft.✓�SP/AYNG2�f� Phone: (�fay,� yoy o y� 8 <br />,� r7�rr, <br />Tolal Cost fo Inslall Device (/rom confracforinvoice): 5 �,�7 �v <br />Please verify the followfng: <br />�am the owner oi the property where Ihe haclnvaler prevenlion device was installed. <br />�vorked with Ihe contractor to determine the location for the backwaler prevention device and <br />u ersland lhat the decision regarding Ihe localion of the device was mine. <br />My contractor instructed me how to access, inspect, and maintain the device. <br />�nderstand that I am responsible (or maintaining lhe back�vater prevention device and keeping <br />d m good working order, unless il is instailed in the city righboi-way. <br />If I sell my property, I will make potential buyers aware oi Ihe backwater prevention device and <br />the need to inspect and maintain it on a reguiar basis. <br />�m enclosing all of the necessary papenvork (use the yellowRebate 5ubmittal Checklist). <br />Seicct from the following: <br />The contraclor idenlified downspouls or olher drainage Ilines thal were connected to my sewer <br />I�e (belween m� house and ihe inslalled device) and removed, or rerauted lhem. <br />o my knowledge, my pwperty has no downspouls or olher drainage connecled lo my sevaer line <br />�b�hveen my house and Ihe inslalled device). <br />'e are downspouts or other drainage lines connecled lo my sewer line (between my house � <br />the installed device). I undersland that lea�ing Ihese conneclions creates a iisk of (looding <br />I accepl thal risk. • <br />Signature Date - "�S <br />I; f� <br />1+Y1 . <br />