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�,�}� Backwater Prevention Device Rebate Program <br /> �^��,., Rebate Application Form <br /> ��'.. <br /> � ------- --- — -- --- -- � <br /> ; PropertyOwnerName. C1i�{n � �/'a[� -��z ��K�✓'"�. <br /> Installation Addiess. /�/3 `/ �R/r^��� �V� � <br /> � Cit Cver'��" State: !��' Zip 9�Zo / � <br /> Y <br /> I <br /> � Rtaihng Address(ildilferenQ. <br /> I� City: _ Sla�e Zip <br /> � <br /> Email: _ Phone ( )_ � <br /> � <br /> I Total Cost lo Install Device (lrom cont�acfor invoicef 5 2 Z�9 �"�ryc I <br /> I ----- _ --- --- � <br /> Please verify the following: <br /> �I am Ihe owner o`the property���here the backti•;ater prevenGon device vras installed <br /> ❑ I worked wl;h the contraclor to determme lhe Iocation for Ihe backwater prevention dewce actl <br /> understand lhal the decision regardmg the localion of the device was mine. <br /> �] hAy contractor inslructed me how to access, inspect, and mainta�n the device. <br /> � I understand that I am responsible tor maintaining the bac!avater prevenlion device and keeping <br /> (" d in good work�ng order, unless it is mstalled in the ciry right-of-way <br /> h� If I sell my property, I will make potenhal buyers aware of the baclnvaler prevention device and <br /> T-� the need to inspect and mainlain it on a regular basis <br /> � � I am enclosing all o(the necessary papenvork(use lhe yellow Rebate Submittal Checklist) <br /> Select irom the following: <br /> ❑ The contractor identified downspouts or olher drainage Ilines that were connected to my se�ver <br /> I�nc (between my house and the installed device) and removed, or rerouted them. <br /> �_� To my knowledge, my property has ro dovmspouls or other drainage connected to my sewer line <br /> (behveen my house and the installed device). <br /> n There are downspouts or other drainage lines connected ro my sewer line(behveen my house <br /> and the installed device) I understand lhat leaving these conneclions creates a nsk ot Oooding <br /> and I accept that risk <br /> Signaturc � �.� Date /���/�/s - <br />