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4 Backwater Prevention Device Rebate Program <br />zrrr Rebate Application Form <br />Property Owner Name: Lf_5 f - -� 5/L r Ae Len '� - A- / l& N <br />Installation Address: q / <br />City: �� �r�_ Slate: zip:36 <br />�� <br />Mailing <br />//Address (if different): le. l e /V PmP�3/� _ <br />City: State: � rt� — Zip. eza <br />Email: l�J 1�9 R�� 1Vl �Ol aetQl<,N Phone: (y7��7- <br />/ro <br />Total Cost to Install Device (from contractor invoice): S <br />Please ify the following: <br />am owner of the property where the backwater prevention device was installed. <br />[Vi worked with the contractor to determine the location for the backwater prevention device and <br />ly Zunde tand that the decision regarding the location of the device was mine. <br />contractor instructed me how to access, inspect, and maintain the device. <br />understand that I am responsible for maintaining the backwater prevention device and keeping <br />t in od working order, unless it is installed in the ci.y right-of-way. <br />ff f I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the aped to inspect and maintain it on a regular basis. <br />\[}�T am enclosing all of the necessary paperwork (use Gie 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 />jv1 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 these connections creates a risk of flooding <br />and I accept that risk <br />Signature Ze 2` Date fe2—Is <br />