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�' <br />Backwater Preventiun Device Rebate Pro�ram <br />Property Owner Name: �; <br />C <br />Installalion Address: <br />City:� <br />Mailing Address (i(di(ferent): <br />City: <br />Rebate ApplScatios� Form <br />I i <br />.. �� - —� - r . � <br />State: <br />� <br />Email: Phone:�%� ���=�5/0� <br />Total Cost to Ins!all Device (from contracfor invoice): $_� ��� __ <br />Please verify the fallowing: <br />[; I am the owner of the property where the baclavater preven6on device was inslalled. <br />� I worked with the contractor to detetmine the location for ihe back�vater prevention device and <br />understand that the decision rec�arding the location ot the device was mine. <br />['( My contractor inslrucled me how lo access, inspecl, and maintain the device. <br />�I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the cily right-of-way. <br />[,� I( I sell my property, I will make potentiai buyers aware oi lhe backwater prevention device and <br />the need to inspect and maintain it on a re;�ular basis. <br />[J(I am enclosing all of the necessary papenvork �use lhe yellow Rebale Submitt�l Checklist). <br />Sctect from the following: <br />❑ The contraclor identified downspouts or other drainage Ilines ihal were connecled lo my server <br />line (bchveen my house and lhe installed cevic��) and removed, or rerouled ihem. <br />(� To my knowledge, my propeRy has no downspuuts or other drainage connected to my sewer line <br />(behveen my house and lhe installed device). <br />❑ Thcre are downspouts or other dr2inage lines connected to my sewer line (betwecn my house <br />and the installed device). I understand that leaving lhese conneclions creates a risk of flooding <br />and I accepl that risk. <br />Signature i Date � _�� ^ �� <br />