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�, <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />� <br />Installation Address: 7b� Z �PLt�-�l. /7V� <br />City: G �1�8^rN/1 State: � Zip:��� <br />Mailing Address (if diHerenf): �pI % �J � � <br />City: SNO�W»�i�_ State: W� Zip:�6 <br />Email: r�BNr�P.rLYrn��n��.nP� Phone: ry�✓ �S�'�33/ <br />Total Cost to Install Device (from confractorinvoice): 5 oC."\a���� <br />Piease verify the following: <br />[� I am the owner of the property where the backwater prevention device was installed. <br />�I worked with lhe contraclor to determine the location for the.backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />� My contractor instructed me how to access, inspect, and maintain the device. <br />�I under.tand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />[� IF I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />� I am enclosing all of the necessary paperwork (use the yello�v Reb2te Submitlal Checklist). <br />Select from the following: <br />❑ The contractor identi(ied downspouts or other drainage Ilines lhal were connected to my sewer <br />line (behveen my house and the installed device) and removed, or rerouted them. <br />� To my knowledge, my property has no downspouts or other drainage connected to my se�ver line <br />(belween my house and the installed device). <br />❑ There are downspouts or other drainage lines�connecled to my sewer line (between my house <br />and the installed device). I understand Ihat leaving these connections creates a risk of flooding <br />and I accept that risk. <br />��/���� �S <br />SJgnatuie bafe __�f "� /� <br />