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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: aoD -1 Z&" //P A .o _ <br />Installation Address: <br />City: �yPie7 r State: <br />Mailing Address (if different): / 2 R0 <br />City: e e-eA We State: ee44 Zip: 9 8/ 2 S" <br />2t 6 <br />Email: Phone: <br />Total Cost to Install Device (from contractor invoice): S _ <br />Please verify the following: <br />I am the owner of the property where the backwater prevention device was installed. <br />I worked with the contractor to determine the location for the backwater prevention device and <br />understand 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 />e 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 />(-Jf 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 />JR I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts 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 Ihnse connections creates a risk of flooding <br />and I accept that risk. <br />Signature 27.1", ;�..1 Date <br />