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Backwater Prevention Device.Reba4e Program <br />� ' Rebate Application �orm � � <br />Property Owner Name: _ <br />� <br />InstallatlonAddress:—"'"� 1 � a`� � �� <br />City: �2 i St�te: .. � Zip: � �L �, ` <br />Mailing Address (flahffen9ntJ: <br />City: <br />Stete: <br />ZP� <br />Emall: �I M��-�Lt v�v�L-e %' C'"M'�sti • I.6W` Pho�o: (�-C'� )�L� Q 2A'�Z-:- <br />a <br />Tatal Cosi to Install Dev�ce (hom contractorinvolca): $ 3� ��' �— , <br />Pioase veriiy the.(ollowin�: <br />�am the awner of Ihe property where lhe Gackwal�Y pfevention devloe waa irietelled. <br />�worked wilh Ihe conVador to delertnine iha bcaUon (or �e beckwater�prevenGon devico and <br />undcrsland that 1he dedalon rt+gartling lhs bcauo� of ihe davice was mine. <br />�Jly ooMraclor Instructed me how to accdas, insped, flnd malntein the devke. <br />[�(undetstend that I am responslble for malntaining the backwater preventlon devloe aruf keeping <br />it in good working order, unlesa it ia ine1a11ad In the clty rlgM•of-way. • <br />Q�11 I sell my property, l w11I make potenUal6uyars awere of lhe batkwatm preventan device and <br />thn nnAd tn Ins�ed and malntain it on a repular basls. <br />f om endosing oll of the necessary pnpervrork (uso lho yellow Rebate Submklal Checklist}. <br />Select irom the tollowing: , <br />❑ I'ih�o contwaen my�house nd thse nUsleiQd doWoece a�d IIm ved, or r�er�outed memd ro my sewer <br />To my knowledgo, my ptopoAy has no dowrtspouls or olher drainege corrnected to my sewer Ilne <br />�botwoen my houso and the Instelled dovlce). <br />❑ There ere downspouts or olfier dreinage lines oonnected ta my sewer One (baMraen my houso <br />ard lha inalolled devlx). I�mderstnnd that leaving th000 oonn�ctlons creates a risk oi flooding <br />and 1 eccept Usel risk. <br />�"' , <br />Slgnat�rro Daro �i ` � '+,. • � 5— <br />