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� Backwater Prevention Device Renate Program <br />Rebate Application Form <br />Property Owner Name: _ — �` � �� `� �� . � �.'� , - : � — <br />Inslallation Address�. �� '��•�- � ���� <br />Ciry: ' �,:. � Siate • • Zip .�. �., , , � <br />h7ailingAdtlress(ifdi//erent): ��1� �� �'� • �� - - <br />Gity� � 1-• ,•, � i Siate Lp �.S ?' �. � <br />EmaiP. . - c ., '1.• , � .:.t � Phone: (,,.t�) ��.t�� .� �j..., ;��. <br />Tolal Cost to Install DevicN (from contractorinvorceJ: 5 <br />Please verify Ihe following: <br />/ <br />[.�'I am the owner o( the pruperty where fhe backweder prevenlion dev�ce �vas inslalled. <br />�'I worked with the conlractor lo delermine lhe localion for the backwaler preveati0n tl2vice and <br />understand Inat the decision regardinq the IecaUon o( the tlevlce was mine. <br />['Nly con�ractor mstructed me how io access, mspect, antl mam.tain the device. <br />�I underslantl Ihat I am responsible lor maintaininy the backwater pre�-enlion device and kecp��nc� <br />it in good �vorking order, unless It is installed in Ihe cily right�of•vray. <br />�{• II I sell my propeny. I will make pmenlial buyers a�vare ol ihe �ackwaler prevention dev�ce and <br />Ihe need lo mspecl and maintain il on a regular hasis. <br />❑ I am encbsin9 all of Ihe necessary papenvork (use the yellow Rebate SuUmlllal Checklisq. <br />Select from the following: <br />(]'The coNractor iAentihed downspouls or other tlramage Il�nes Ihal were connecled to my sewer <br />I�ne (betwcen rny house anA Ihe installed dev�ce) and removed, or rerouted Ihem. <br />�-J To my knowletl(�e, my property has nc tlo�vnspouis or olhcr drainaqe connected to my sewer line <br />(between my house and Ihe mstalled device). <br />{] Their, are downspouts oi other tlrainapc hnes connecicd 1� my sewer linc (beIWCL'll RlY IIOUSC <br />antl Ihe installetl tlevice). I understand Ihat leavin9 Ihese connections cre�tes a risk ol flooding <br />and I accepl thnt nsk <br />Slgnafure �-----, r.11.�..\—.._ Date �, i r �;-•,, `,' <br />� <br />