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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property O�vner Name: /7 e2ti/� r o 1�� e s <br />Installation Address: � � _ � J ___ <br />City: ! JP-2�-�� State: LriA Zip: y�ao/ <br />Mailing Address (d ddferent): <br />City: <br />Stale: <br />Email:�.�GGr,l�nl�n�Ap�Ra�/v �.o�+ Phone:(`�d�j ��aa�t�° <br />Tolai Cost to Install Device (from contraclor im�oice): 5 �u�' �- 30 <br />Please verify the following: <br />��/ am the owner of lhe properly �vhere lhe back�vater prevenlion device was inslalled. <br />worked wilh the contractor to determine the location for Ihe backwater prevention device and <br />undersland thal the decision regarding the location of the device was mine. <br />[�1y contractor instrucled me how to access, inspect, and maintain the device. <br />� I undersland lhat I am responsible for main�aining �he back�vater prevention devlce and keeping <br />it in �ood working order, unless it is instalied in the city righl-o(-way. <br />j� If I sell my property, I will make potential buyers aw�are of the backwater prevention device and <br />the need to inspecl and maintain it on a regular basis. <br />i <br />0' I am enclosing all o( Ihe necessary paperwork (use the yello�v Rebale Submillal Checklisl). <br />Select from the following: <br />�lie contraclor idenlified do�+�nspouts or other diainage IGnes Ihat were connected lo my sewer <br />line (bebveen my house and lhe installed device) and removed, or rerouled Uiem. <br />Fyj� To my knowledge, my property has no dovmspoul, or olher drainage connocled to my sewer line <br />(t�elween my house and the installed device). <br />�J\ <br />U�1 There are downspouls or other dralnage Iines connected to my sewer line (between my house <br />and ihe installed devicx�). 1 imAersfand th�l leavin� these cnnnectinns creates a risk ol Oonding <br />and I accept that risk. <br />i �/. <br />Signature "`-`�"'"`"`�" ���'� Date �� /� _ <br />