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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Namo: I`�'�� �"�l.i��-/ __ <br />Inslailation Address: _�� C� C�^�� �✓t <br />City: ���,�,�� _ State: � <br />Mailing Address (d diNerent): <br />City: <br />Email: <br />State: <br />Total Cost to Install Device (Irom confracforinvoice): 5 <br />Phone: ( <br />Please verify the following: <br />j� I am the o�vnr.r of Ihe property �vhere the back�valer prevention device was installed. <br />� I worked with the conhaclor to detertnine the localion for the backwater prevention device and <br />� understand that Ihe decision regarding the localion of the device was mine. <br />j�J My contractor inslructed me how to access, inspect, and maintain the device. <br />� I undersland that I am responsible (or mainlaininc� �he backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />� If I seil my properly, I v�ill make polential buyers aware of Ihe backwaler preventioii device and <br />the necd w inspect and maintain it on a regular basis. <br />j�l I am enctosing all ol the necessary papenvork (use Ihe yelbw Rebate Submdtai Checklist). <br />Selecl irom the folluwing: <br />❑ I he contracior identilied downspouls or other drainage Ilines ihat were connc:cled to my sewer <br />line (belwcen my house and ihr, installed device) and removed, or rerouted Ihem. <br />� To my knoviledgn, my proporty h�s no downspouts or ofhr� draina�e connecled to my sewer hne <br />(bete�cen my housr, and !he instatled device) <br />j_ j ihere are downspouls or olher drainage lines conner.led to my sevier line (between my house <br />and Ihe inslalled device). I undeistand lhat leaving these wnnr_�r.tions creales a risk a( flooding <br />and I accept that risk. <br />, / � <br />SignatureJ�� / � �/ ./��� Date <br />� - <br />S �:�8" � (S� <br />