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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property O�vner Name: �c' -� � �. � �c4LLG-r�l� -rF� <br /> Installation Address: � g �� -r-'- �.4aci� � v-G�K��- <br /> Ciry: 1� �CC-�C_="rT Slate: W 64 Zip: �'�� ( <br /> Mailing Address(ildilferentJ: -- <br /> City: �---' State: - Zp: __ <br /> Email: — ___ Phone: (42s) 2_S 1- !3Z f? <br /> iTolal Cost lo Install Device (/rom confracforinvoice): S <br /> please verify the following: <br /> : <br /> �.am the owner c�the property vahere the back�vater prevent�on device�vas installed. <br /> � worked vaith the conlractor to delermine the location for lh� backv�ater prevention device and <br /> understand lhat the decisinn rzgarding the location of the d^.vice was mine. <br /> [✓�My coniraclor insiructed me how In access, inspeot, and maintain the device. <br /> �understand that I am respons?ble (or maintaining ihe backwater prevention device and keeping <br /> �Fin good working order, unless it is installed i� the cily righ!•ot-way. <br /> If I sell my property, I will make potential buyers aware of the back�vater prevention device and <br /> the need lo inspect and maintain it on a regular basis. <br /> [J1 I am enclosing all of the necessary papenvork (use the yello�v Rebate Submiltal Checklist). <br /> Select from the following: <br /> ❑ The contractor identified downspouts or other drainac�e Illnes that were connecled to my sewer <br /> li e(between my house and the installed device)and removed, or rerouled them. <br /> r� To my knowledge, my property has no downspouls or other drainage connected to my sewor line <br /> (between my house and the installed device). <br /> ❑ There are downspouls or other drainage lines connected to my sewer line (belween my house <br /> and B�c installed device). I unders[and that leaving these connections creates a risk of flooding <br /> and I accepl that risk. <br /> Signatu ���-e{:� Date S ` �/ ( ��-� <br />