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Backwater Prevention Dev�ice Rebate Program <br />Rebate Applicztion Form <br />Property Owner Name: � � v i vi �¢YJl�t V <br />InstallationAddress:�UT C���ti�� /�t-c <br />City: _�ve vC l l Sl•alc: Vr ki Zip: G S Z G I <br />Mailinc� Address (i(di(femnt): <br />Cify: <br />Emall: <br />State: <br />Phone: (-�zr� 3z� - I�rJ� <br />Total Cost to Install Device ((rom confracfor invoice): $ 2, Q�1 S� Z Z _ <br />Plcase verify the following: <br />(� 1 am the o�vner of the property where the backwaler preveniion device was inslalled. <br />[Jf I�vorked v�ith Ihe contraclor to determine the location for the back�vater prevention device and <br />understand that the decision regarding fhe Iocalion of lhe device was mine. <br />(� My contraclor instrucled me how to access, inspecl, and maintain lhe device. <br />[� I understand that I am responsiblo for maiMaming the backwator provontion device and keeping <br />it in good v�orking order, unless it is installed In the city right-of•�vay. <br />�!f I sell my property, I will make potenlial buyers aware of lhe backveater prevonlion device and <br />the need lo inspect and maintain il on a regular basis. <br />�J I om enr.lnsiny �II of Ihe necessary papervaork (use the yr.11ow Rebate Sut�mitta' Checklist) <br />Select From the following: <br />❑ The r,ontrar.lor identilied downspouls or other drainac�e Ilines that vae�e connecled b rnl ;ewer <br />�I c(Uetween my house and the InstaOed devlce) and removed, or reroulyd thern. <br />o my knowledge, my properly has no do�vnspouts or Nher drainage connected to my sev�er Ime <br />(between my housr, and �he inslalled dovlce). <br />❑ There are downspouts or olher drain�ge lines conneUed to my sewer line (belween rny house <br />and lhe Installed devlce). I undercland'had h:aving Ih�esr_ comicclions crcates a rick of flooding <br />and I accept that risk. <br />I ' <br />� /�� v _� l',�/ <br />Si,qnafure_��t �Z (�� Date d o`� /� <br />. -� <br />