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Backwater Prevention Device Rebate Program <br /> Re�ate Application Form <br /> Property Owner Name: `�Gv�f �V I I C 5 Z`U1""'` <br /> Installation Address: �0 I � o���I��'� <br /> City:�\i�F �� State: \� Pr Zip: � �ZQ � <br /> Mailing Add�ess(il dilferent): <br /> City: Stale: _Zip: <br /> Email: Phone: ( )_ <br /> Total Cost lo Install Device(hom contractorinvoice): 5 <br /> Please verify the following: <br /> � I am.the owner of the property evhere the backwater prevention device was installed. <br /> � worked wilh lhe conlractor to determine the location for lhe backwaler prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> �My contrzclor instrucled me hov✓to access, inspecl, and maintaiii the device. <br /> � I understand thal I am responsible for mainlaining lhe backwater prevention dzvice and keeping <br /> it in good working order, unless it is installed in the city 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 inspect and mainlain it on a regular basis. <br /> � I am enclosing all of the necessary papenvork(use the yellow Rebale Submiltal Checklisl). <br /> Select from the following: <br /> �The contracior identi(ied downspouls or other drainage Ilines lhat were conne�led lo my sewer <br /> line(behveen my house and lhe installed device)and removed, or rerouled lhem. <br /> �To my knowledge, my property has no downspouls or other drainage connected lo my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouls or other drainage lines connected.to my sewer line (beN�een my house <br /> and the installed device). I understand that leaving these conneclions creates a risk of flooding <br /> and I accept that risk. <br /> Signature_�� r Date <br />