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Backwater Prevent�on Device Rebate Program <br />Rebate Application Form <br />PropeAy Owner Name: _D � G ia l� P: �-J (.� N��— <br />Installalion Address: `''f /Gf �', <br />City: �I�1�8-V'�� Slate: <br />Mailing Address (i(dif(emnt): <br />City: <br />Email: <br />Total Cost to Install Device ((rom contractorinvoice): 5 <br />Please verify the following: <br />z�p: y Sr�.i/ <br />Phone: ( <br />I am the owner of the properiy where ihe backwaler prevention device was inslalled. <br />I worked with the conlractor to determine the locaeion for the backwater prevenlion device and <br />understand that the decision regarding ihe localion of the device �vas mine. <br />My contractor inslructed me how to access, inspect, and mainlain the device. <br />I understand that 1 am responsible for mainlaining Ihe hackwater prevention device and koeping <br />it in good workmg order, unless it is installed in the city right-o4v�ay. <br />If i sell my property, i will mako potential buyeis aware of Ihe backwater prevention device and <br />the nced to inspect and mainiain il on a regular basis. <br />I am enr.losing all of the necessary paperv�aik (use the yellow Rebalc Submitlal CheckllsQ. <br />from tite followin�: <br />[I� The conlractor identificd dov.nspouts or olher dr;�inage Ilines Ihat were conner.ted to my sevacr <br />( Ilne (belween rny h0use and the installed tlevlce) and removed, or rcroufed tliem. <br />❑ To my knowledge, my properly has no downspouts or olher drainage connr-cted lo my sevder line <br />(hetween my house and lhe inslalled device). <br />�There are downspouls or olher drainage Ilnes connected to my sevder line (belwcen my liouse <br />and the Installed device). I understand lhal leaving Ihese conneclions croates a risk of flooding <br />( and I acr.cpt lhat risk. <br />SignaNtre V�"`Qnv'u�/ ' ��r��'_aate � �C� lS� <br />_ � -- <br />