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6ackwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> — ------._---,---------------._...-- --- <br /> Property0wnerName: 'F��C� �/����1`�� _ <br /> InstallationAddress: ,� � � I ��;^'� �� ��'e-- <br /> �1._.. '^ �+ <br /> City:�„��-i.� Slate: ��'1 Zip: { � a'� � <br /> Mailing Address(il dil/erentJ: <br /> Ciry:_ Stale: Zip: <br /> Email: _ _ Phone: ( ) • <br /> Total Cost to Ins[all Device(Irom contracfor invoice):$� � <br /> Please verify the following: <br /> �am the owner of the property where Ihe backwaler prevention device was instatied. <br /> (� I worked with the contractor lo delermine the localion (or lhe backwaler prevr,nlion device and <br /> understand that the decision regarding the localion of lhe device was mine. <br /> [VJ My conUaclor instructed me ho�v lo access, inspect, and maintain lhe device <br /> �I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, uNess it is inslalled in lhe city righl-of-way. <br /> [�If I sell my property, I will make polenlial buyers aware of the backwaler prevenlion device and <br /> the need to inspect and maintain it on a regular basi,. <br /> �'I am enclosing ell o(the necessary paperwork(use the yellow Robate Submillal ChecktisQ. <br /> Select from lhe(ollowi�g: <br /> ❑ The contractor identified downspouls or other drainage Ilines Ihal were connecled lo my sewer <br /> line(belween my house and Ihe installed device)and removed, or rerouted them <br /> ��To my knowledge, my property has no downspouts or other drainac�e connected tu rtry,ewer line <br /> (between my house and the inslalled device). <br /> • ❑ There are downspouts or olher drainaye lines connecled to my sewer line(between my house <br /> and the installed device). I understand that leaviny ihese conneclions creates a risk of flooding <br /> and I accepl that risk. <br /> Signature � Date � ( �� �O r j <br />