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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ovmer Name: �� ���"�" ����5 — <br />T' . � <br />Installation Address: 4�0 �7 ��rl P r'a � ''`� ' - <br />_L.2%�� P � �-L-�' I <br />Cily: �(/v��'e-� State: � Zi : <br />h4ailing Address (il dilferent): Sa-/>'L�-- <br />City: ��`1 State: � Zip: <br />Email: <br />Phone: ( <br />Total Cost to Install'Device ((rom contracfor invoice): S� 77:'__ �7 <br />Please verify the following: <br />��am the owner of the property where the backv+ater prevention device was installed. <br />�Iworked �vith the contractor to determine the location tor ihe backwater prevention device and <br />` understand that the decision regarding the location of the d=vice was mine. <br />��9y cor' �ctor instructed me how to access, inspecl, and maintain the device. <br />�I understand thal I am responsible for maintaining the backwater prevention device and keeping <br />it in good �.vorking order, unless it is installed in the city right-of-way. <br />'� Ii I sell my propeRy, I will make potential buyers aware of the backwaler prevention device and <br />the need to inspect and mainlain it on a regular basis. <br />� I am enclosing all of the necessary papenvork (use the yellov� Rebate Submiltal Checklist). <br />�� <br />Select from the following: <br />� The conhactor idenli(ied downspouls or other drainage Ilines lhat were connecled lo my sewer <br />line (behveen my ho� •: and the installed device) and removed, or rerouted them. <br />:(�To my knowledge, my property has no downspouts or olher drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouls or other drainage lines connected to my sewer line (behveen my house <br />and the Installed device). I undersland that leaving fhese connections cre�tas a risk of ilooding <br />and I accept that risk. <br />Signatu� ���-�� Date 4 � b I� <br />