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Backwate� Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: ��"��� �'�� <br /> Installation Addmss: �� GG�-�iY.i� b`t?�_ <br /> CitY�—1.��`��� State: �f/ia— Z�p: �0 LO� <br /> Mailing Address(ifdifferenQ: <br /> CiIY� State: 7�P_ <br /> Email:_ ILCV `� N�-v�C �' (.,� �<m i �n.�/� Phone:( ) 25�1— ^1�Z85 <br /> Total Cost to Instail Devioe(ftom contracforinvoice):$_ �,33p . Gc� <br /> � <br /> Please veri(y the followiog: <br /> Q"I am the owner of the property where the backwater p2venHon device was instelled. <br /> 0`I worked with the contractor to determine the loption for the backwater prevention device and <br /> understend that the decision regarding the IocaBon of the device was mine. <br /> D�My coniradof instrvcted me how to access,inspect,and meintain the device. <br /> [�'I understand that I am responsible for maintaining the 6ackwater prevention device a�d keeping <br /> it in good working order,untess it is instalied in the cily�ight-of-way. ' <br /> 0"If I sell my property,I will make poten4al buyers aware of the beckwater preveniton device and <br /> the need to inspect and mainteln tt on a regular basis. <br /> ❑ I am enctosing all of the necessary paperwork(use the yellow Rebate SubmMhal Checklist). <br /> Selec!from the following; <br /> �''fhe wn�rador identified downspouls or olher dralnage Ilines thet were connected to my sewer <br /> line(between my house and the instailed device)an�remwed,or rerouted them. <br /> ❑ To my knowiedge, my property has no downspouis or other drafnage connected to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage Ifnes connected to my sewer line(between my house <br /> and the instalied devfce). I understand that leaving Mese conneGions creates a risk oF Ooodfng <br /> and I acaept ihat risk. <br /> �j�� <br /> Signature ISL�'-Q p,� $--�-7 y �� <br />