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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name:.0 <br />Installation Address: s:j p? 61 1) <br />City: ?A(a gs Stale: - ..Zip: <br />Mailing Address (if different): 1: __ _ <br />City: 1 A , State: <br />LIP _ A <br />Email QQ �v ,1-4 - W % �I 1 Phone: �J W O -463% <br />Total Cost to Install Device (from cor,:; actor invoice): $ alf51- 30 <br />Please verity the following: <br />JR I am the owner of the property where the backwater prevention device was installed. <br />U"l worked with the contractor to determine the location for the backwater prevention device and <br />understand that thn 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 prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />If I sell my property, I will make potential 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 of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Setect from the following: <br />❑ The contractor identified downspvuts or other drainage (lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />[� To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature L'��` =L�� _ ,-y� Date ! s— <br />1 <br />