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� <br />� <br />Baakwater Prevention Device Rebate Program <br />Rebate Application Form <br />PropeRy Owner Name: <br />Installation Address: � I o � ��^'U �� <br />City: � State: "�/� Z,P: 9 a�o� <br />Mailing Address (Hdillerent): <br />��y; State: Zip: <br />Emai�V� . lT/� .�� Phone: (2c6� R16 - S�`I 6 <br />Total Cost to Install Dev�e (irom contractorinwlce): S <br />Please verify lhs following: <br />[� I am the owner of the property where the backwater preventlon device was installed. <br />[v�l worked with the contrador to detertnine the location for the backwater prevention device and <br />understand•that the dedsian regarding the bcalion of the device was mine. <br />['f My contractor instructed me how to access, inspect, and maintain the device. <br />� understand that I am responsible for maintaining lhe backwater prevenUon 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 oi lhe backwater prevendon device and <br />% e need to inspecl and maintain it on a regular basis. <br />0 I am enclosing alI di the necessary paperwork (use the yellow Rebale Submittal Checklist). <br />Seleet from ths fdlowing: <br />[�J The contractor identiiled downspouts or olher drainage IBnes that were connected to my sewer <br />Iine (between my house and the installed device) and,removed, or rerouted them. <br />j� To my knawledge, my property has no downspouts or other drainage wnnected lo my sewer line <br />(between my house and the installed device). <br />�There are downspouts or other drainage Iines connecled to my sewer line (behveen my house <br />and the instalied device). I understand that leaving thes� conneGions creates a risk of flooding <br />and I accepl that risk. <br />Signarore� �•"'"" �� 'r � d O''� <br />