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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> PropertyOwnerName: �US� DiA-N^� US'S'e�/ <br /> Installation Address G f +`/8'N� ve- <br /> City:��P e�_State:�it.�/r Zip:_ " �01 <br /> �vlailing Address (il dr((erenfJ: ��O l7 7 � �`� � ��� . <br /> City: e State: !/lJ�" ._Zip: � , <br /> / I ,il� /� G�/�`/� .UJv�hone: [��'Z�l 7 �i <br /> Email: �VeCIC i A l"�J <br /> Total Cost to Install Device (Irom contracloi invoice): S � ���� f - - � <br /> Please verify the following: <br /> (j� i am ihe o�aner of the property where the backwater prevention device was installed. <br /> '� I worked with ihe contrector to determine the location for the backwater prevention c'evice and <br /> understand that the decision regarding the location of the device was mine. <br /> �ij My conlractor instrucled me how to access, inspect, and maintain the device. <br /> �, I understand that I am responsibte for maintaining the t�ckwater prevention device and keeping <br /> it in good �vorking order, uniess it is installed in the cily right-of-way. <br /> �Q,If I �eil my property, I�vill make potential buyers aware of the backwaler prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> �I am enclosing all of Ihe necessary paperwork (use the yellow Rebate Submiltal Checklist). <br /> Select from the following: <br /> ❑ T��� ^ontractor identified downspouls or olher drainage Itines thal�vere connected to my sewer <br /> linc ,between my house and Ihe installed device)and removed, or rerouled them. <br /> � To my kno�vtedge, my propeRy has no downspouts or other drainage connecled to my sevier line <br /> (between my tiouse and the inslalled device). <br /> � � There are do�vnspouls or other drainage lines conneGed to my sewer line (between my house <br /> and lhe installed device). I understand thaf leaving these wnnections creates a risk of flooding <br /> and I accepl that:isk. <br /> / /, <br /> Signaturc � � Date <br />