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Backwater Prevention Device Rebate Proyram <br />Rebate Application Form <br />Property O�vner Name: <br />Inslallallon Address: <br />1CU7'" <br />�t��o C-02.��' <br />ciry: , �1/uc� state: !�'�.y _ <br />Maiiing �ddress (71 diNerenl): �'�� Y � � �'r <br />Zip:,--�5'�.�'� l <br />�� <br />Cily; _ ti ��'7! E'�'-- State: � �/ _� Zip: t� �v�G� <br />EmaiL �EI"�R1f�ec� �1��1riu.� �, t ��:ti Phone: ��} ���-��6 <br />Tatal Cost lo Install Devica ifi�m conbacrorinvwce): 5�,sc�./ <br />Please v2rify the Tollowing: <br />[�'1�am th� awner of the properiy where the bacKwater prevention device was mstalled. <br />� worked wilhdhe contractor to determine the (ocalion tor the backwater ptevention device and <br />undersland Ihat lhe decision regarding Ihelocation of lhe device v+as mine. <br />[�iGly cortraclor instructed me how to access, mspect, and mainlain the device, <br />[,j�i'unde�siaod that 1 am responsible tor maintaining the hackwaler prevention device a�d keeping <br />II in go��d working order, uNess it is inslailed in Ihe city right-of-way. <br />[�ffl sell my property, I will make polential buyers aware ot ihe back�vafer prevenGon deWco and <br />Ihe nefad to insped and maintain it o� a rAgular hasis. <br />(��m enclosir3 all of the necessary papervro�k (use lhe yellnri Rebale Submitlal Checkhslj, <br />Select trom the followingt <br />[j The tmitractor identilied downspou�s ur olher drainage Ilines ihat were connecled to my setia•r r <br />Ilne (bc3tween my house and the Instailed device) and removed, or rerouted them. <br />?o my knotvledge, rtty proporty has no downsp0uls or �ther draln�go connected to my sewer hne <br />(between my house and the inslalted dedce). <br />❑ There are downspouts or uther drainage lines connecfed to my sewer llne (belween my house <br />.�nd the instailed davice). 1 underslana Iha1(eaving ihese connections creales � risk oF Booding <br />and I eccept that dsk. <br />.,_-,,�J�% / i � <br />5ignature /'�' ..�G . ' -�rY�9( _-�-,-lLdate J�-� <br />