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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property owner Name: (�1t� All,I <br />Installation Address: -71 ! i7loyT AJG <br />City: E-Vt t ' _ State: Zip: %87f'I <br />Mailing Address (if diNerpnt): S A Mtn <br />City: State: Zip: <br />Email: Phone: (crzn 439 —Di��� <br />Total Cost to Install Device (from contractorirwoice): $ 2•.SGt✓. �� <br />Please verify the following: <br />4�1-fam the owner of the property where the backwater prevention device was installed. <br />Fj-I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the dec;sion regarding the location of the device was mine. <br />[-My contractor instructed me how to access, inspect, and maintain the device. <br />[j I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />Olf I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />Ef I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature Date GJ <br />