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Backwater Prevention Device Rebate Program <br />E„ Fie6ate Application Form <br />�_ – ----- - --- — - -- –� <br />Property Oaner Name: /7�c/9 � _ l I`C[LC� <br />� �1 � <br />InstallationAddress: <? 7/l (�/�Cii�� �I- ✓G-. <br />I <br />� City � /! C � r,.� State: �� 2ip: 9 �� �� ' <br />I <br />t�lailing Address (if diHerent): <br />City: <br />State: <br />Email: ---- Phone �5'�} �oZ' �Z+^%% <br />i— <br />�i � 4 � �/',�• <br />Tolal Cnst to Install Device (Irom confractor invoice): $ �- �"'—�7�0� <br />� <br />Please verify the following: <br />['�I am the owner uf the property �vhere Ihe back�vater preve� fion devicc .�as mslalled. <br />i�% I e�orked wdt the conlractor to determine the location for lhe backwater prevention device and <br />� understand thaf ihe decision regardiny the location of the device was mine <br />�'7 tviY contractor insiructed me how to access, inspect, and maintain the device. <br />[�]� I understand that I am reeponsibte for maintaining the backwaler prevention deoice and keepiny <br />d In good �vorking order, unless it is mstalled in lhe city righf-of-way. <br />�•1 If I sell my property, I will make polenbal buyers aware oi thc back�vater prevention device and <br />the need to inspect and mainlain il on a regular basis. <br />��� I am enclosing all o( ihe necessary papenvork (use the yellow Rebate Subrniltal Checkl�st) <br />Select from the (ollowing: <br />I_�J� The contractor identified downspouts or olher draina,ye Ilines lhat weie connected to my ,e�ver <br />line (between my house and lhe inslalled dewce) and removed, or rei:uted Ihem <br />�l ; o my knowledge, my property has no downspouts or olher drainaye connected to my sewer line <br />(bePNeen my house and lhe inslalled device). <br />!� Riere are do�vnspouts or other drainage lines connected lo my sewcr line (between my house <br />and Ihe inslalled device). I understand Ihal leaving lhese connections creales a risk of flooding <br />and I accept that risk. <br />i-� , - ;:—r � <br />�' <br />Signature:.'`— u..,- �`ti�!�""�^-t�_ Date %�� /, x'� / 5 <br />- i � <br />