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Backwater Prevention Device Rebate Program <br />E,, Rebate Application Form <br />PropeRyOwnerName: ���N�C �� �����-5=-"��� <br />Installation Address. � b �� G�"�� � I� <br />�� �, <br />City: �" �� � State �/`f� 7ia <br />Mailing Address ;J dillerenf): �' 1M� <br />City: <br />Email: <br />Stale: <br />Total Cost to Instail Device (l�om confra:.tor invoice): 8 <br />Please verify the following: <br />— -------- —� <br />F-1� �'l� Li�1�l����2- <br />Phane:( <br />�am the owner of the property where the back�vater prevenlion device was inslalled. <br />?„J' I worked with ihe contractor to determine the Iocation for the backv�ater prevention device anC <br />� understand that the decision regarding the location oi the device was mine. <br />�' 1h y coMraclor ins:ructed me how to access, inspect, and maintain the device. <br />�I understand that I am responsible for maintaining the backwater prevention device and keeping <br />�n good working order, unless it is inst �l Fd in the ci;y righl•of-.vay. <br />�If I sell my properly, I will make potenhal buyers aware ot the backwater prevenlion device and <br />th need to inspect and mainlain it on a�egular basis. <br />/ I am enclosing all of the necessary papensork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />;./ The contractor identi(ied do�ti�nspout� or other drainage Ilines that �vere connecled lo my sewer <br />hne (beM�een my house and the 'nstnlled device) and removed, or rerouted them. <br />.�J 7o my knowledc�e, my property has no downspouts c� other drainage connected to my se�ver line <br />(between my house and the installed dewce). <br />(_j There are downspouts or other drainage �ines connected to my setver line (belween my house <br />and tha installed device). I understand tnal leaving lhese connections creates a risk ot Iloodiny <br />and I accept thal risk. <br />(' _ nI,,\ L�Z�2`� � >> <br />Signature �,lV.°Q_ ��`�i �J Date <br />l <br />