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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> ProperlyOwnerName: �Vla����e 1`�1��'��"��Z�1'�' <br /> Inslailalion Address: ����1� I ���C��Q,� r��i <br /> Cily• �e���ll Slale. vVQ" Zlp: -1�2�� <br /> Mailing Address(il diHerenQ: �V b�� �33�� <br /> 7 <br /> City: �i�'e��� Stale: J/�_2ip: �8� � <br /> Email: Zb1ADYQI,tQ�.1l�Qa\�1�llll� � �� Phone: (�1S) �a�l g�� <br /> Total Cost lo Instali Device(lrom contracfor invoice): 5__�3��'1�•�� <br /> Please verify the foilowing: <br /> [/f I am Ihe owner of the property where the backwaler prevenlion device was installed. <br /> [� I worked wllh the conlrector to delertnlne the location 1or the backwater prevenlion devicc antl <br /> undersland that the decision regarding the location ot lhe device was mine. <br /> Q� My contraclar inslructed me how to access,inspecl, and mainlain Ihe device. <br /> [.� I undereland Ihal I am responsible(or mainlaining the backwater prevention device and kaepinp <br /> it in good working order, untess it is installed in Ihe city righf-o(-way. <br /> [� If I sell my properly, I will make potenlial buyers aware of the beckwater prevention device and <br /> the noed to inspecl and maintain il on a regular basis. <br /> [�1 am enclosing all of the necessary papervrork(use the yellow Rebate Submitlal Checklist) <br /> Solect from the Tollowing: <br /> ❑ The confraclor idenlified downspouts or other drainage Ilines that were connected to my sewer <br /> li�e(6etweon my house and Ihe inslalled device)and removed,or rerouted Ihem. <br /> [�To my knowledgo,my propeRy has no davnsF�ula or other draina�e connected to my sev�or lino <br /> (between my house and the inslalled device). <br /> ❑ There are downspouts or other drainage Ilnes connecled to my sewer Iine(beM�een my house <br /> and the installed device). I undersland Ihat leaving these connectlons creates a risk of flooding <br /> end I accept lhat risk. <br /> % <br /> Slgnafuro � -� Dato � �/� <br />