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Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> - --_ --- ___ __ - - ------- <br /> Property Oovner Name: r?u�'___�+ur1�/,y <br /> � <br /> I <br /> Installation Address: j�G _�en�e'Y S% <br /> City:�!V-�/��'1' State: _w 9' Zip:�v�Zc/ <br /> Potailing Address (ildifterent): Zco9 We�rc/d f��e,_ I <br /> Ciry: Tv�.'e�� State: w4 Zip: �fs'�a/ I <br /> Email: Phone: (yzs) "LSz ��67'L ' <br /> TotaLCost to Install Device((rom contrector invoice): $ ?Sc�� �I <br /> _ J <br /> Please verify the following: <br /> �a'I am lhe owner of the property where the backwa!er prevention device was installed. <br /> [�]'I worked wilh the contracto!to delermine lhe localion for the backwater prevention device and <br /> understand that the der,ision regarding ihe lo�ation of the c'evice v�as mine. <br /> [vj� My contraclor instructed me how to access, inspect, and maintain the device. <br /> 0�I understand that I am responsible for maintaining the backwater prevent�on device and keeping <br /> it�good working order, unless it is installed in the city right-o6tivay. <br /> ��Jlf I sell my property, I will make potential buyers a�vare of the backwater prevention device and <br /> lhe need lo inspect and mainiain it on a regular basis. <br /> Lj'I am enclosing all o(the necessary papenvork (use the yellow Rebate Submittal Checklist). <br /> , Select from the following: <br /> I I The contractor identified doemspouls or other drainage Ilines that were connected to my seefur <br /> line(belween my housc and Ihe installed device)and removed, or rerouted lhem. <br /> ;_� To my knowledge, my property has no downspouls or other drainage connected to my sewer line. <br /> �heriveen my hnuse and the installed device). <br /> ;�J" Thcre are dovmspouls or otfier drainage lines connecled to my sewer line (between my house <br /> and,the installed devir.e). I understand that leavinp these connections creales s risk of flooding <br /> and�l accept Ihal risk. <br /> , � <br /> Signature ��f�7'�`% � �'"`'%�`�i Date � � G ��} <br /> ✓ <br />