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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application� Form <br />Property Owner Name: � h i-^ •'c- � ( � t.., o <br />Installation Address: �� 77 b ( ' ( �% � J ' <br />City: � v r' c tL— State: b•i L� Zip: `I a�,D l <br />Mailing Address (i/diHerenl): <br />City: State:__ Zip: <br />�jti � -� <br />Email: n�r'�}� (��i.vP � 4oj•L� ^�. Phone;(' ) Zy�3-� ,� .; <br />Total Cost to Instail Device ((�om contraclor invoice): $ ���� •—�� <br />�1 <br />1' <br />Please verify the following: � � •: % <br />� I am the owner of the property where lhe'backwaler prevention device was inslalled. <br />� I v+orked with lhe contraclor to determine lhe loca:�on for the backwaler prevention device and <br />undersland ihat tlie decision regarding the location of the device was mine. <br />� My contractor instructed me how to access, inspect, and maintain the device. <br />�- I understand lhat I am responsible for mainlaining the backwater prevenlion device and keeping <br />it in.good working order, unless il is installed in the city right-of-way. <br />-�, IF I sell my property, I will make potenlial buyers aware o( the back�vater preven�ion devite and <br />the need to inspecl and mainlain it on a regular basis. <br />(�I am enclosing all o( the necessary paperv+ork (use Ihe yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The conlraclor idenlified downspouts or other drainage Ilines that were wnnected to my sewer <br />[�line (behveen my house and lhe inslalled device) and removed, or rerouted Ihem. <br />To my knowledge, rny property has no downspouls or other drainage connected lo my sewer line <br />(between my house and Ihe installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I cnderstand ihal leaving Ihese conneclions creates a risk of (looding <br />and I accept lhal risk. <br />Signafure�""�' ✓ "�- Date��3lri <br />