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Bacicwater Prevention Device Rebate Program <br />Rebate Application Form <br />PropeAy Owner Name: 1�D,0.rN' e vt /Ia.n�� <br />Installalion Address: z3 zt2 N a__�4 /an.' iLtiP <br />City: L✓r,"(Y � State: A,✓/'� Zip:��o2l1 / <br />Mailing Address (il diHerentJ: <br />Cily: <br />State: <br />Email: P N,cuM N,�. hv y� ��� •Ga,�c Phone: (j6o) 9/02- Sd�'c� <br />Total Cost to Install Device (/rom contracforinvoice): $��9 � <br />Please verify the tollowing: <br />�am the owner of the properly where the backwater prevention device was installed. <br />�worked wilh lhe contractor to delermine lhe location for the backwater prevenlion device and <br />understand that the decision regarding the location of the device was mine. <br />[}�My contractor inslructed me how to access, inspect, and maintain the device. <br />�understand that I am responsible for maintaining the backwater prevention device and keeping <br />il in good working order, uniess it is installed in the city right-of-way. <br />�t I sell my property, 1 will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�am enclosing all of lhe necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identi(ied downspouts or other drainage Ilines that were connected to my sewer <br />line (between my house and thc installed device) and removed, or rerouted Ihem. <br />[�To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and lhe installed device). <br />❑ There are dowrspouls or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand lhat leaving these connections creates a risk ot flooding <br />and I accept that risk. <br />// � <br />Signature������ � � Date .2' 3— /5 <br />