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Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Property Owner Name: ��2. _ <br /> ,,r //� � �- ��-, ,, I <br /> Installation Address: _�LV �/� i <br /> � ---�- <br /> City:�f`'���•f/�� --State: �_ z��:��am J <br /> , tvtai ifng Address(if diNcrentf. _ __ _ <br /> � <br /> ; Cily: _� Sta�e: Zip: <br /> I EmaiL — - -- - - — — — Phone: (KaS) ���' Z��7i I <br /> � Total Cost to Install Device ((rom confracfor invorcel: 5 4�5 � � I <br /> I <br /> Please verify the following: I <br /> �am the owner of the property where the backwatei prevention device was inslalled. I <br /> [�I worked with lhe conlractor to delermine the location for the backwater prevention device and <br /> understand lhat lhe decision regarding lhe location oi the device was mine. <br /> �v{ My conUactor instructed me how to access, inspect, and maintain the device. <br /> [✓� I understand lhat I am responsible for maintaining Bie backwater prevention device and keepin�i <br /> it in good workiny order, unless il is installed in lhe cily right-of-way. <br /> �If I sell my property, I will make potential buyers aware o(the backwaler prevenUon device and I <br /> the need to inspect and maintain it on a regular basis. <br /> [��I am enclosing all of the necessary papenvork (use ihe yellov. Rebate Submiltal Checklisq. � <br /> Seleat from the following: <br /> {�1 � <br /> �The contractor identified downspouls or other drainage Ilines that were connected to my sewer � <br /> line (beMreen my house and the inslalled device)and removed,or rerauled them. � <br /> v[]�To i�y knowledye, my property has no do�,vnspouts or uther drainaye connecled ,o my sewer line <br /> (behveen my house and the installed device). <br /> ❑ There are downspouts or olher drainaye fines connected lo my sewer line(behveen my house <br /> and Ihe in;talled device). I understand that Ieaving tf�,ese connec(ions creales a risk of O000�nr� <br /> and I accept lhat risk. <br /> ���,,,CCC',,, �,,,, ,,, ���� <br /> Signaturb,� Datc �'�" � � <br /> � <br /> I <br />