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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ovmer Name: <br />Installation Addrass: ����f[�� ��_ y� v <br />Cily:�; � , State: �qJf� Zip:�.�U� <br />Mailing Address (if diNerent): <br />City: <br />Slale: <br />Email: SW � e ¢� �(%r�i � � • �_�11 Phone: (4-'�j _�Z. -���.� <br />J <br />Total Cost to Instali Device (from contractorinvoice): $ <br />Please verify the following: <br />[�J I am ihe owner of the properi� where the backwater prevention device was installed. <br />� I worked with the conlraclor to delertnine the location (or ihe backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />� My conlraclor inslrucle�l me how to access, inspect, and maintain the device. <br />�, I understand lhal 1 am responsible for mainlaining the backwater prevention device and keeping <br />it in good working order, �nless it is installed in the ciry right-of•way. <br />� If i sell my property, I will make potential buyers aware oi the backwater prevention device and <br />lhe need lo inspecl and maintain il on a regular basis. <br />[j� I arn enclosing all of tlie necessary paperwork (use the yellow Rebate Submiltal Checklist). <br />Select from the following: <br />j� The contractor identified downspouls or other drainage Ilines that �vere connected lo nry sewer <br />line (between my house and the installed device) and removed, or rerouted lhem. <br />[] To m�r knnwledge, my propeiiy has no downspouts or other drainage connecled to my sewer line <br />(behveen my house and ihe inslalled device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (bet�veen my house <br />and the installed device). I understand thal leaving ihese connections creales a risk of 1looding <br />and I accept that risk. <br />� • <br />Signat�ir Dafe I Z` /�' L.L�� <br />