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Backwater Prevention Device Rebate Program <br />Rebate A�plication Form <br />�ropertyOwnerNarc,e `�I�W���'Yv _ <br />InstallationAdd�ess 2 (��_�-"�K}�� __��J <br />City: YJ� i� State. � Zip: �__ O2�_I �! <br />Maihng A�dress (iI dilferent): rL7Q7_ ���V_{�'i ' I <br />p i <br />� City �V��N/��_-_— State:-Y�-�1---Z�P �_V2i�1__ . <br />I Email Y_IYIV��l/-�-�U�LY�1l1� S— Phone: �G.� �� �'�t�O:J% <br />Total Cest to Install Device (Irom contrac�orinvoiceJ: S���1- R� __ <br />Please verify the following: <br />�( I am the owner of the property where lhe back�valer preventlon device was installed. <br />v� <br />[� I �vorked �vith the contractor to determine the location for lhe backwater preventio� device and <br />undcrsland that the decision regardmg the location of the device was mine. <br />� My conlractor inslrucled me hov: to access, inspect, and mainlain the device <br />(� I understand Ihat I ar*� responsible for mainiaining the backwater prevenlion device and keepiry <br />il in good working order, unless d is ms�alled in the city right-of-�vay. <br />!� If I sell my p•opehy, I will make potenti�l buyers aware of the back�val?r prevenlio� device and <br />lhe need lo nspect and mairtain il on a regular basis. <br />�IJ I am r.nclosing all ol the necessery paperwork (use lhe yellow Rehate Submittal Checklist) <br />Select from !ne followin3: <br />[_j The r.ontraclor idenli(ied downspruts or oUier drainaye Ilines ihal were connecled to my sewer <br />�ine (behveen my house and the inslalled device) and removed, or rerouted lhem. <br />,�To nry knowled�e, my property has nu downspouls rn other dramage connected to my sewer line <br />(hetween my housc �nd lhe installed device). <br />❑ There are downspouls or other drainage lines conn�cted lo my sewer line (behveen my house <br />and the installed device). I understand that leawng Ihese �:onnechons creales a risk of flooding <br />and I ar.cept that nsk. <br />Signature �%� - �, Date / / � � <br />--7 <br />