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� Sackwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> r-- — <br /> Property Owner Name: ' ` IM�e(�Ge �IQ�Se-(� <br /> InstallationAddress:��l troy�' QfL <br /> Ciry:_�P�4.�i State . F�-�� Zip:�� � <br /> Ma{ling Address(ildiNerent):�l'� 'S, Q� �-f <br /> aiy:��a- fe�norl State: I�1� z�P: 982�� <br /> Email: NC�I�E.(� � l���A,�om phone: (a-�"y %�'�l ��oOZ <br /> Totat Cost to Inslall Device (lrom confractor invoice): 5 <br /> 1 �ase verify the tollowing: <br /> j� 1 am ihe owner oF the property where the bac'cwater prevenlion dsvice was Installed. <br /> ❑ I worked with the conlractor to determine (he location for Ihe backwater prevention device and <br /> und�rstand ihal the declslon regardirg Ihe locallon of the device was mine. <br /> ❑ My conlractor instructed me how to access, inspecl, and maintain lt.e device, <br /> ❑ I undersland Ihal I am responsible for maintaining tho beckwaler prevenlion device 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 wlll m�ke potentiel buyers aware o(tho backwater preventlon device and <br /> the need to Inspect and malntaln It on a regular basis. <br /> ❑ I am enclosing all of the necessary papervrork(use the yellow Rebale Submittal Checklist). <br /> Select from the following: <br /> ❑ The conlraclor ldentifed downspouts or other drainapA Ilines thet were connected to my sewe; <br /> line(between my houso and tho installed device)and removed, or rerouled them. <br /> ❑ To my knowledge, my property ha;no downspouts or other drainago connected to m;� sewer line <br /> (belween my houso and the Installad devlce) <br /> ❑ There are downspouts or other drainac�e Iines connecled to my sewer Ilne(belween my house <br /> and Ihe in3tailed device). I understand Ihat leaving these connedlons creates a risk of Oooding <br /> end I accept that risk. <br /> � Signature � Date 7 � <br />