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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />i— -- — - -- _. <br />� Property Owner Name: �v��- `��� _ <br />Installalion Address: i V �`%Z�� �_ <br />City:'�1/�� Stata _�__ Zip' C�U '- U <br />�utailing Address (ddillerent): ___ <br />City: __ _ _ State: <br />� Email: Phone: ( ) <br />ITotal Cost to Install Device (Irorn conUactorinvoice). $�2�T • <br />Please vcrify the following: <br />(��m the ovmer of the property where the backwater preveMron device was instaUed. <br />�worked with the contrador to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mire. <br />[�contractor insiructed me how to access, inspect, and maintain the deuice. <br />��nderstar.d that I am responsible for maintaining the back�vater prevention device and keeping <br />it in ood �vorking order, uniess it is insta!led in the city right-of-way <br />l I sell my property, I��nll make potential buyers aware of the backwater preven�ion device and <br />the need to inspect and maintain it on a regular basis <br />am enclosing all of the necessary paper+rork (use the yelloa+ Rebate Subm�ttal Checklist) <br />from the following: <br />;1 The contractor identdia,d dovmspouts or olher drainage Ilines that v�ere connected to my sewer <br />Gr.e (behveen my house and the mstalled device) and removed, or rerouted them <br />(�' io my knowledge, my property has no downspouts or ollier dramage connected to my sewer line <br />(behveen my house and Ihe installed device). <br />- There are downspouts or othn• drainaye lines connected lo my sewer line (behveen my house <br />and the insta�led device) I u�derstand Ihal leaving these connechons creates a risk of Ilooding <br />and I acc�ept that iisk <br />Signatur __ _ __ Oate��� <br />