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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property O�vner Name: ������C� <br /> Installalion Address: _ � ?i Z�o_(�cQ,.���1 •'�'t �P - <br /> City: ��..��_State:_(��_Zip:�S�i ZC�� <br /> tilailing Address(il dif(erenO� <br /> Ciry: State� _ Zip: _ <br /> Gmail: ��,,,r � �Q1J��y�c�,JflV�f Phone: (�,5) '3!N —�OY�1 <br /> Tolal Cost to Install Device (Irom contractorinvoice): $_��fi 6� <br /> �_ _ � a-�- ,�'-�w <br /> �.��r� �� <br /> Please verify the following: ����,J �r �;.(SS <br /> �am the owner o(the property where the backv�ater prevention device�vas inslalled. `�^��^� �,1"'� <br /> U <br /> �lil worked�vith ihe contractor to determine the location for the backwater preven;ion device and �,�loy �"`�"' <br /> 1` understand that the decision regardmg the location ot the device was mine. <br /> Z J�/IS" <br /> (vty cenlractor inslructed me how to access, inspect, and maintain the device. <br /> �I understand Ihat I am responsibie for maintaining the backvlater prevention device and keeping <br /> il in good working order, unless it is installed in ihe city right-oi-a�ay. <br /> �f I sell my property, I will make potential buyers a�vare of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> �!- I am enclosing all of the necessary papenvork (use the yellow Rebate Submiltal Checklisl) <br /> ,j. <br /> Select irom the following: <br /> �] The conlraclor identified downspouts or olher drainage Ilines that were conneded lo my sewer <br /> line (oetween my house and the installed device)and removed, or rerouted them. <br /> }�/To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> j�(between my house and the installed device). <br /> �] There are do�vnspouts or other drainage lines connected to my sewer Iine (beRveen my house <br /> and the installed device). I undersland that leaving these connections creates a risk of flooding <br /> and I accepl lhat risk. <br /> Signatwe �/�`�� � � Date��_ <br />