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� Backwater Prevention C�evice Rebate Frogram <br /> E„ Rebate Application Form <br /> — � <br /> � Property O�vner Name: �I OP1�`� 'L �C'" 1 �n'�(�`�'f <br /> I Installalion Address: '�r / ��7 � �� <br /> Ciry: r��i<�-J Sfate: W/�' ZiP. �1�`Z-o� <br /> Mailing Address (il dilferenf): <br /> i City: _,_ State: Zip: _ <br /> Email: Phone: (� c� 3�j �Z _ <br /> To1al Gost to Install Device (lrom contracror�nvoice): 5_��rYi�' — <br /> I — — <br /> Please verity the following: <br /> � �] I a lhe o�vner of the property r+here the backwaler prevention device was installed. r <br /> I vrorked wilh the contractor to determine the location for lhe backviater prevenlion device and <br /> undersland that the decision regarding fhe localion of the device was mine. <br /> � � <br /> [J N1y contractor instructed me how to access, inspect, and maintain the device. <br /> � I undersland th::' I am responsible(or maintaininy the backv�ater prevention device and keeping <br /> it in good�vorking order, unless it is inslalled in Ihe city right-o(-way. <br /> �.�J If I sell my property, I will make potential buyers a�vare o(the back�valer prevention device and <br /> the need lo insper.t and maintain it on a regular basis. <br /> �] I am enclosing all o(the necessary papervvork(use the yeilo�v Rebate Sub�nittal Checkl�st). <br /> Scle�t from the following: <br /> �hc coMractor identified do�vnspouts or other drainage Ilines that were connected lo my se�ver <br /> li�le�(between my house and the installed device)and removed, or rerouled thr.m. <br /> � �my knowledge, my property has no do�vnspouls or ofher dr3i��age cannecled lo nry sevrer line <br /> �belween my house and lhe insialled device). <br /> [_J There are downspouls or other drainaye lines connecled lo my sewcr line (bel�veen my house <br /> and lhe installed device). I undersland that leaving these conneclions creales a risk o(flooding <br /> and I accept that risk. <br /> i�i� – <br /> c�// _ Date' �2 – �" 2n1� - <br /> Signature -- <br />