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Backwater Prevention Device Rebate Program <br />Q, Rebate Application Form <br />Property Ovmer tJame: , G'1 �_�' -►' ' l�il �'� C°�W h.� <br />InstallaGonAddiess:_`1_�� _�{(n_a.�_y�_______.__—_ <br />City: �v{��_-----Slate: _�/�ZiP:__�Q�� <br />hlailing Address (if ddferent): __ _ _ __ ! <br />I <br />City' _ State: Zip � <br />Email: � c�� ,W �� �_�n'C�s^1_ti.Q �- __ Phone: (���G Zi G `�} ;� <br />Total Cost to Install Device ((rom contractorinvoice): 5__�(,v_ _ ____ � <br />- -1 <br />Please verify the fol�ow:ng: <br />�am the ov:ner of the property :vhere Ihe backwater prevention dewce was installed <br />�•�orked w�th th,; r.ontractor lo determine the location for the back�vater prevention device and <br />undersland that the dedsicn regarding lhe location of the device was mme <br />�h•1y contractor inslr�cted me how to access, inspect, and maintain the device. <br />��understand that I am responslbte for maintainmg the back�valer prevention device and keeping <br />it in yood �vorking o�der, unless d is mstalled in the city nghl-o6�vay <br />�If I sell my property, I will make polential buyers aware of the backwaler prevention device and <br />the need to inspect and mamtain it on a regular basis. <br />/r' I am enclosing all oi thr ner.essary p�{�envork (use the �elloc; Rebate Subm�ttal Che. klist) <br />� <br />Sclect from thc followinc�� <br />L] The conlractor idenldied dov;nsputds ur olher drainage Ilines Utat •::er�, connecled to rny se�::er <br />c(between my house ond U�e installed dewce) and removed, or rerouled Uiem. <br />To my knowledge, my property has no downspouts or other drainage connected to my sewei I�nc <br />,. (between my house and llie mslatled device). � <br />[_� There are downspouts or other drainage lines connected lo my ��ver line (bet�veen my house <br />and Ihe installed device) I understand that lenwng thes� connecuons creat�s a risk of floodmg <br />�n <br />Signa <br />� <br />Date � ��� ��� <br />