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�' <br />Back�nrater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation Address: <br />City: (�v¢rdY=i'� State: l.J� Zip: "I go� � <br />Mailing Address (if di//erent): <br />City: State: Zip: <br />\ 6�0.� • Ca•�•-. <br />EmYil• �"`,,.� I� Sl� _ �� � Phone: (q�,:� ) 34S �a J� <br />Total Cost to Install Device (from conlracfor invoice): $ ___ <br />Please verify the tollowing: <br />j� I am the owner of the property where the backwater prevention device was installed. <br />� I worked with the crontractor to detertnine fhe lucation for the backwater prevenlion device and <br />understand thal ihe deciEion regarding Iha location ot ihe device was mine. <br />� My cont, actor instructed me how to access, inspect, and maintain ihe device. <br />[� I understand lhal I am responsible (or mainlaining Y�e `ackwater prevenlion device and keeping <br />il in good working order, unless it is instailed in the .:..y right-of-way. <br />� If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspecl and maintain it on a regutar basis. <br />j�J I am enclosing all ot the necessary paperv✓ork (use the yellow Rebate Submittal Checklist). <br />Select (rom the (allowing: <br />❑ Ttie contractor identified downspouls or olher drainage Ilines that were connected to my sewer <br />line (between my housc and the installed device) and removed, or rerouled them. <br />� To my knowledge, my propeAy has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />[] There are downspouls or olher drainage lines connected t� my sewer Iine (between my house <br />and ihe installed device). I understand that ieaving lhese connections creates a risk of flooding <br />and I accept that risk. <br />Slgnatu►e l � � Date � I� • /_� <br />