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�^%�� Backwater PreventEon Device Rebate Program <br /> Rebate Application For� <br /> Properly Owner Name:�Ll lA, �✓��-C� <br /> Installalion Address: I�t l�j�G'� <br /> City._.�, l' State:.�f�� Zip:— ` ��ZG� <br /> Ivlailing Address(i(diNerent): _ <br /> City: -- State: Zip: <br /> Email: Phun��)� �7�� ���I <br /> _ _ � rI � v <br /> iolal Ca t to Insla!I Device (from confractcrinvoiceJ $_�_�� `I ` <br /> Please verify the following: <br /> � I am lhe owner of lhe property where the backwa�er prevention device was ins�alled. <br /> / <br /> � worked with �he conlraclor to delermine lhe location for Ihe backwater prevention device and <br /> understand that the decision regarding the location o(the device was mine. <br /> �y contractor instrucled me how to access, inspect, and maintain lhe device. <br /> I understand lhat i am reeponsible for mainlaining Ihe backwaler prevention device and keeping <br /> il in good working order, unless it is installed in•the city right-of-�vay. <br /> �f I sell nry property, I �n�ill make polenlial buyers aware of lhe backwater prevention device and <br /> th need lo inspect and maintain il on a regular ba�is. <br /> I am enclosing all o(ihe necessary papeiveork (use lhe yellow Re�bate Submittai Checklistj. <br /> Select fram ttie following: <br /> ❑ The contraclor idenlified downspouls or other drainage Ilines lhat vrere connecfed to my sewer <br /> hne(between my house and thc installed device)and removed, or rerouled lhem. <br /> �o nry knovAedge, my property has no downspouls or olher drainage connecled fo my sewer line <br /> � jbelween my house and the inslalled device). <br /> [] There are downspouts or olher drainage lines connected lo my sewer line (between my h�use <br /> and the installe.d device). I understand Ihat leaving these connections creates a risk�i flooding <br /> and I accept lhat risk. <br /> I Signature ����- Date <br />