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— --— —�- -- -- -- -- _.--- <br /> Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Property Owner Name: � u Z.Q111�e. M P:}-2 f r <br /> InstallalionAddress: �a�, a I—u-��� S '� <br /> City: L UQ,.re--�"}- Stale� _��Zip: Q O ZO I <br /> Mailing Address(if dil(erenl): <br /> City: State: _Zip: <br /> Email: ' Phone: (' ) � ' .__ . <br /> Total Cost to Install Device (lrom confractor invoice): S <br /> Please verify the following: <br /> � Fam lhe owner of the properiy where ihe backwater prever,tion device alas installed. <br /> ?� I worked with the contrector ro determine Ihe location for the backwater prevention device and � <br /> understand that the decision regarding the location of lhe device was mme. <br /> ❑ My contreclor insiructed me how to access, inspect, and maintain the device. NO <br /> i� I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> d in good working order, unless it is installed in the city right-of-way. <br /> �Q If I sell my property, I tivill make potential buyers aarare of the back�vater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> t}(J I am enclosing all of the necessary paperwork (use the yellow Rebale SubmiHal Checklist). <br /> Select from the following: <br /> [] The contractor idenfified downspouls or other drainagc Ilines that were connected to my sewer <br /> line(behveen my house and the installed device) and removed, or rerouted them. <br /> � To my knovAedge, my property has no dovmspouls or other drainage connected to my sewer line <br /> (between my housc and the installed device). <br /> n There are downspouts or other drainage lines connecled to my sev�er line(behveen my house <br /> and the installed device). I understand that leaving these connections creales a risk of flooding <br /> and I accept ihat risk. <br /> Signature CS,�II/ZQ/Yl/i��. �rn �/11 z ,�/�O�L�,Date�� �S <br />