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�, <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form � <br />property Owner Name: <br />� <br />Installatlon Address: q l� \ L<�`� l�1 �" <br />City: �Z � State: U� Zip: ��� 1 <br />Mailing Address (lldiA'eranf): <br />Cily: <br />State: ZiP:_ <br />Emall: �� � � G�..t v� v��-! � ��vw1-Il • i.6�^ti Phono: � ) �'� Q ���-- <br />0 <br />Totai Cost to Install Device ((rcm contraclor InvofceJ: $ 3� 3 v' <br />Please verlfy the following: <br />[J�am Ihe owner of the prope�ty where the backwater prevenlion device was inetelled. <br />�worked wilh Uw contractor to dalermine the bcaUon fa the baGcwamf prevention device and <br />undcrstend that the dacision regarding the bcaUon of the device was mtne. <br />[�iAy oontractor InsWcted me hrnr to access, inspecl, and malntein the devloe. <br />[�(understend that I am responsible for mainteining the bac:kwater prevenFon Aevlce and Keepirg <br />il in good wa�4cing order, unlesa it ia instelled ln the cky right-cf-way. <br />[�'If I sell my prapeAy. I wlll make potential buyers ewere ot the backwafer provenfron devica and <br />the nend to In� and malntain it on a repular basls. • <br />I em endosing all of tho.necessary paporwork (uco thn yellow Rebwte Submfttal Checklisl). <br />Select irom the following: <br />❑ The contraclor idenlifled dovmspouts or othor drelnage Illnes thal were conneded to my sewer <br />line between my house and the insfallad device) and removed, or rerouted ��xn• <br />To my knowledgo, my propeAy has no downspouts or other drainege connected to my sewer iine <br />(betwean my house and tfio :r�lbed devlce). <br />❑ There are dowr�spouts w otlier drainage lines oonnected to my sewer Me (behveon my house <br />erd the insleiled devioe). I undorsfnnd that leaving these cannectlorts creates a risk ot flooding <br />end I eccepl tl►nt rlsk. <br />� <br />Slgnature <br />Date G • z z' �5 <br />