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% <br />Backwater Prevention Device Rebate Program <br />Rebate Application Forrn <br />Property O�vner Name: v"e a l%^e�l�t— �� �.���i � S <br />Installation Address: ______��' �J/"�ir_l� ��'��� • <br />City: �P/...c�t.[�� �State: G�i7V"— Zip: �,Y�7-�� <br />fvlailing Address (ildif7erentJ: __�%jGt "-c./ _ <br />City: <br />Email: <br />State: <br />Zip:_ <br />Phone: ( <br />Total Cosl lo Install Device (lmm confracforinvoice): S �i�� •�� <br />Please verity lhe following: <br />[c�l am the ovmer of the property where the back�vater prevention device was inslalled. <br />[, LI'varked with the contractor to determine lhe location (or the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />[�Ay contraclor insiructed me how to access, inspect, and maintain the device. <br />[�I understand that I am responsible for maintaining Ihe backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. ' <br />�If I seli my property, I wili make potential buyers aware of the backwater prevenlion device and <br />the need to inspect and maintain il on a regular basis. <br />�I am enclosing all of the necessary papenr�ork (use the yellow Rebale Submiltal Checklist). <br />Select irom the following: � <br />y(�The contractor idenlified dovmspouls or other drainage Ihnes that vrere connected lo my sewer <br />hne (between my house and the instalied device) and removed, or rerouled them. <br />❑ To my knowledge, my property has no ao�vnspouls or other drainage connecled to my sewer line <br />(behveen my house and the installed device). <br />❑ There are downspouts or other drainage lines conneUed to my sewer line (between rtiy house <br />and Ihe inslalled device). I understand thal leaving lhese connections creates a nsk of Ilooding <br />an 1 I accept lhat risk. <br />/'// <br />Sign t�ur' e —�cl-�[-� ��'ju`�Date � �i"�4 = /S � <br />----%✓� — - �__� <br />