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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: --,0�✓ u�0���i�"� _ <br />Instalialion Address: � 3 �F C�tp,�� <br />� <br />City: i.�-,E��_ State: G✓�" ZiP: —��_ — <br />�4ailing Address (if diNcrent): <br />City: _ State: _ Zip. <br />Email� ��orovr,.�� 6' ��. GOr-1 Phonc: (�/'i5) Z�L—$//� <br />Total Cost to Install Device (Irom conUacfor invoice): S�_._p � <br />Please verlfy the foilowing: <br />f�l am the ormer of lhe property where Ihe backr�ater prevenlion device was installed. <br />�I worhed with the contracbr to determine the location for the backwater prevention devir.e and <br />understand Ihal the decision regarding lhe location of the device �vas mine. <br />�My coNraclor inslructed me how lo access, inspecl, and maintain the device. <br />jtr I undersland Ihal I am responsibte for ma�ntaining Ihe backwater prevonlion device and keeping <br />it in good working order, unless it is mslalled in the city right-of-way. <br />� If I sell my proporty, I will make polential buyers aware ol Iho backr�a�er prevention device ano <br />the need �o inspect and maintain it on a regular basis. <br />� I am enclosing all ol the necessary paperwork (use Ihe yello�v Rebale Submittal Checklist�. <br />Select Irom the following: <br />U The ccniraclor identified downspouls or other drauiage Ilines that wore connected to my sewer <br />6ne (beRveen my house and Ric installed device) and removed, or rerouted them. <br />[j To my kno�vledge, my property has no downspouls or other drainage connecled to my se�ver line <br />(bMwcen my house and the installed devlcc). <br />��%� There are do�•mspouts or other drainage Imes connected to rny sewer Ime (betv�een my house <br />and the �nstalled Aevice). I understand ihat leaving lhese connections creates a nsk of flooding <br />,�nA I ar.cept ihat nsk. <br />/ i� <br />Signature <br />9� ���� n..--'•L Dafe ?_— lj —'7,. L%�T <br />✓ <br />