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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: H-��2V� fT• �r•lC-V� <br /> Inslallation.Address: �� � l`�(-laV�cL �'1�P V��l'� <br /> Cily: E�C�1�e •t-�- State:-1Lv.�Zip: �-^�-E1� <br /> Mailing Address(i(diflerenf): <br /> City: State: Zip: <br /> Email: Gl I''n�OIV.r''E?Y1C��CUW1(Ct�'}' Yle't- Phone: (zp���(o-y S �:3 <br /> Totai Cost to Install Device ((rom contractor invoice): S��0�. �p� <br /> Please verify the following: <br /> I am the owner of the property where the backwater prevention d=vice was inslailed. <br /> �worked with lhe contraclor to determine the localion for the backwater prevention device and <br /> understand lhat the decision regarding the location of the device was mine. <br /> [�j My contraclor inslructed me how to access, inspect, and maintain lhe device. <br /> ? b I und�• �tand that I am responsible for maintaining ihe backwater prevenlion device and keeping <br /> � i[in good working order, unless it is installed in the city right- -wav. - <br /> If I sell my property, I will make potenlial buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> ❑ I am enclosing all o(lhe necessary paperwork(use lhe yellow Rebale Submittal Checklist). <br /> Select from the following: - <br /> ❑ The contractor identified downspouts or other drainage Ilines thal were connecled to my sewer <br /> line (behveen my house and the installed device)and removed, or rerouted them. <br /> [�o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and Ihe inslalled device). <br /> ❑ There are downspouts or other drainage lines connecled to my sewer line (between my house <br /> and the installed device). I undersland that leaving these conneclions creates a risk of tlooding <br /> and I accept thal risk. <br /> Signa�ure C Qf�l Q,Date S- I I ^ IS <br /> �Q . TCr �}e..��t �'�-, �0.C��Soy� <br />