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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Oevner Name: . T�'Q� 1 Q ���0�1 <br />1 <br />Installation Address: !j�� � 2- C11 fCtV�'G� ,�'U� <br />Gity� �V'�'L�. State: V`%li� Zip: 'I$2:U� <br />��ilailingAddress(i/diffe�ent): 1 � P�C��C y�U�� <br />city: �C'�II {-' •V L�`e- State: LU fi' zip: � g(� IS <br />Emai�: G1I�i.� c���4l�1'l�K �V ��3"1Gi,l �.���hore:(�f �� `�(�2 ���J� <br />I� U <br />Total Cost lo Install Device (Irom confractorinvoiceJ: 5_ L 5� ��' <br />Please verify the following: <br />[� � am the ovnier of the property wherc tha backwater prevention device was installed. <br />�-]- I workod wilh the contrador to determine the location ior the backwater prevention device and <br />und�rstand Ihat the decision regarding the localion ot the device was mine. <br />[Y� Nly contractor i�structed me hon lo access, inspect, and maintain lhe device. <br />� I understand thaf I am responsibte foi maintaining the backwater prevenlion device and keeping <br />d in good working order, unless it is inslalled in the city right•of-way. <br />� It I sell my property, I will make potential buyers aware of lhe backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�� I am enclosing all of Ihe necessary paperwork (use the yellovi Rebate Submittai Checklist). <br />Selectlrom.the following: <br />j_ ) The contractor ideMified downspouts or other draina�7e Ilmes th�t were conneded to my sewer <br />line (bet:feen my house and the installed devico) and removed, or r�routed inem. <br />[� To my I nowled9e, my property has no dovmspouts or other drainac�e cannecled lo my sewer line <br />(belween my housc and the insWlled devicc). <br />(1 There are downspouls or other drainage lines connecled to my sewer line (belween my house <br />and the installed device). I understand thot loavmg these connuc6ons creales a risk o( Oooding <br />and I accept that risk. <br />S/gnnture . ___ _ Date <br />