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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />— -- --------- ------- ---- — — --� <br />� � /,� <br />Property Ovrner Name: _,�(J�(�L�Y�� �./r��� c=_ � <br />Installation Nddress � �n����_ J� <br />City: _.�IJ6,2 Ef7' �lale. _ J� Zip:_�� � __ ' <br />h9ading Address (d diNerent). _��p� __ _ __ <br />City: _- ---- State: <br />Email <br />Phone ( ) <br />� <br />pp � <br />Total Cosl lo Install De 'ce ((rom con7ractor invorr.e) S__v2 f_3L.4 p ___ __� <br />I <br />-- - - ----- - � <br />Plcase verify the following: <br />� I arn the owner of the proprrty v�here (he Gackv�ater prevenlion device v�as mstalled. <br />� I�vorked v�ith the contraclor to determine the location tor the backwater prevention dewce and <br />' understand thal the decision regardmg the localion of ihe device �vas mine. <br />d) tity conlractor instructed me ho•+� to acc�ss, inspect, and maintain the device <br />4� <br />[� I understand Ihal I am responsible for mainlaining the backwater preveni�on dewce and keeping <br />it in good working order, unless it is installed in the city righl-oL�:�ay <br />� I( I sell my prope�iy, 1 �vill make potent�al buyers a�vare of the backvla�er prevention device and <br />Uie need to inspect and maintain �t on a regular basis. <br />;;% I am enclosing al! ol the neccssary papenvork iuse tLe ycilo�.v Rebal� Subrnitt�l Checklist) <br />Select from lhe following: <br />;� � he contnclor identi(ied do�a�r.spouls oi olher dralnage Il�nes that �•�ere connected to my sev:er <br />line (belv+een my house and the installed device) and removed, or rerouled ihem. <br />�J To my knowledge, my property has no downspouts or other drainage wnnected to my see�cr hnc <br />(between my house and the installed device). <br />(-] There are downspouts or other drainage hnes connected to my se�ver line (behveen my house <br />and the instalted device). I understand thal leawny these connedions creales a risk ol floodiny <br />and I accept that risk <br />� �i <br />Signature c� _! ��=i� ����C � �� Date �� � ���� � <br />