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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />PropeAy Owner Name: <br />Inslallalion Addressi � Oy �T��'ol� � <br />City: F�'�°� Slale: W�1 Zip: /� 1d I <br />Mailing Address (ildilferent): s�tiw.e. <br />City: State: <br />Email: ���o J� r1'�S n• c�r" _ Phone: (-h� 30�i - I�Y��' <br />Total Cost lo Install Device.(/rom contractor invoico): S_���i'� �•�� <br />Please verify the following: <br />[� I am Ihe owner ot the property whero the backwater preve�tion device was installed. <br />�I worked with the conirector to delermine the location for the backwater prevention device and <br />�nderstand that the decision regarding the location of the device was mine. <br />� My contractor instructed me how to access, inspect, and maintain the device. <br />�I understand that I am responsible for maintaining the backwater prevenlion device and keeping <br />il in good working order, unless it is installed in the city right-of-way. <br />�j If I sell my property, I will make potenlial buyers aware oi the backwaler prevention device and <br />the need lo inspect and maintain it on a regular basis. <br />`fa� I am enclosing atl of the necessary paperwork (use the yellow Rebale Submiltal Checklist). <br />7` <br />Select from the following: <br />❑ The conlraclor identlfied downspouls or other drainage Ilines thal were connected lo my sewer <br />line (belween iny house and the installed device) and removed, or rerouled them. <br />� To my knowled9o, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed dovice). <br />� Thore are downspouts or other drainage lines connected to my sewer line (bolwaen my house <br />and the installed device). I understand that leaving lhese connections creales a risk ot tlooding <br />and I accepl ihat risk. <br />Signature v /" " " � Date 1 — � � - ' S <br />