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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: A R� �- (-{(Z.��E lY �� + F�Tcfc N Z Ae2�TI <br /> Installation Address:�7l/ ND � d*. <br /> City: �v�r'�TT State: �� _Zip:�o�0 � <br /> Mailinc�Address(ildiHerent): _ <br /> Ciry: State: Zip:_ <br /> I EmaiL_ NKO ✓/aNao. Gonn _Phone: (�t� ZT7- 78/0 <br /> �— O <br /> Total Cost to Install Device(from confraclorinvoice):$ ,�y39. B <br /> Please verify the following: <br /> �am the o�:�ner of the property where the b�ckwater prevention device�vas installed. <br /> (� I ivorked�ailh lhe contiactor to determine the location for the bacinvater prevention device and <br /> understand that the decision regarding lhe IocaUon of the device was mine. <br /> �J h4y contractor instructed me how to access, inspect, and mainlain the device. <br /> [�I understand that I am responsible for maintaining the back�vater prevention device and keeping <br /> it in good working order, unless It Is instalied in the cily right-o(-�vay. <br /> [�I(I sell my property, I�vill make potential buyers ativare of the backwater prevention device and <br /> the need to inspe�t and maintain it on a regular basis. <br /> ❑ I am enclosing all of lhe necessary papenvork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> (G1The contractor idenUfied downspouts or other drainage Ilines thal wcre connected to my sewer <br /> line(between my house and the installed device)and removed, or rerouted Ihem. <br /> [� To my knotvledge, my property has no downspouta or other drainage connecled to my sewer Ifne <br /> (between my house and the installed device). <br /> ❑ There are downspoufs or other drainage Iines connected to my se�ver line(behveen my house <br /> and tlte installed device). I understand that teaving these connections creates a risk of Oooding <br /> and I accept that risk. <br /> Signature � Date �'�-7� �S <br />