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� �,�/� Backwater Prevention Device Rebate Program <br /> �� Rebate Application Form <br /> ��--- <br /> Property Owner Name:`� a/ �� N � W / ' `� � � 2 <br /> Instellation Addre;s� � L� � F' �/�ca^"-� � <br /> City: �✓'-'��-�C/`�l State:L'`�°'� 2ip: �g � � <br /> Mailing Address(ifdiNcrenf): _ <br /> City:_ State: 2ip: <br /> Email: "1-�^'� ��n o r 5� ,��.-.cn3'�,h e.�f— Phone:(� ?X� 2 "Z �S 9y- <br /> Total�ost to Install�evice(/rom confrectorinvoice):5 � � �"1 �7 � • (J p <br /> Please verlfy the following: <br /> �am lhe owner oi the properly where the beckwater�revenUon device was instatled. <br /> �worked with the contrector.to detertnine 1he bcation for lhe backwater preventlon device end <br /> undersland that the decision regarding the lawtlon of the device was mine. <br /> �y contractor inatnicted me how to access,Inspact,and maintatn the davlce. <br /> �understend that I am responsible for mainteining the backwater prevenCon devioe end keeping <br /> i�good wottcing order, unless II Is instellad in the city right-af-way. ' <br /> �I(I sell my property, I wlll meke potenllal buyers aware of the beckwaler prevention device and <br /> the need to Inspect and maintain If on a ragular besls. <br /> ❑ 1 am enclosing ell of the necessery paperwork(usa ihe yellow Rebete Submlttal Chedclist). <br /> Select irom the following: <br /> ❑ The contractor identified downspouts ar other dralnage Illnes!hu[were connecled to my sewer <br /> Ilne.(between my house and lhe instelled device)and removed,or rerouted Ihem. <br /> To my knowledge, my property has no Aownspouts or other dralnego connected to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts ar other drainage Ifnes connected to my sewer Ilne(beNvaen my house <br /> end Ihe Installed device).1 understend Ihal leaving these connactlons creates a risk ol0ooding <br /> and I accept ihat risk. <br /> ��� ���/' � Z .� _�s� <br /> Signature �v V'"'"-" Datc � <br /> I <br />