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�,�}� Backwater Prevent�on Device Rebate Pro�ram <br /> ���� Rebate Application Form <br /> ��..�.. <br /> Property Owner Name:�/�I�� �� ��� <br /> Installation Address: /�� � ��f�"�,'e-� <br /> Ciry:�V'�/1iG� State W� Zip:� � <br /> Mailing Address (i(di�lerent): ��_�- � 5i �C � � <br /> City: �'v°- State:J/�I_�_—Zip:CT�! � / .. ._. . <br /> Email:��S C(�. _ �p1yYZ�_1��• � � Phone: (���� `�'C��— <br /> Total Cost lo Inslall Device (from contractor invoice) S_ _ <br /> Please verify tlie following: <br /> (�. I am lhe owner of Ihe property where the backwaler prevenlion device was inslalled. <br /> � I worked with lhe conlraclor lo delermine lhe localiomfor the backwaler prevenlion device and <br /> undersland that Ihe decision regarding the location of the device was mine. . <br /> n My contrador instrucled me how to access, inspect, and mainlain the device. <br /> �c I understand ihat I am responsible for maintaining the bar.kwater prevention device and keepi�g <br /> il in good workinq order, unless it is inslalled in the ciry right-of-way. <br /> (�) I(I sell my property, I will make polential buyers aware o(lhe backwater prevenlion device and <br /> the need to inspec!and maiNain it on a regular basis. <br /> � I am endosing all of the necessary paperv�ork (use�he ycllow Rebale SubmiUal Checklisl) <br /> Select from the following: <br /> n The contraclor identified downspouls or olher drainaye Ilines that were connected to my se�.ver <br /> line (hetween my house and lhe inslallvd device) and removed, or rerouted them. <br /> �io rny knowledge, my properly has no downspouts or olher droinage connecled to my sr.tiver linr� <br /> (belween my house and U:e installed device). <br /> �_J There are downspouts or othei drainage lines connecled fo my sewer line (hetween my house <br /> and the inslalled device). I undrr;tand lhat leaving Ihese connections aeates � risk of flooding <br /> and I acr.ept that risk. <br /> Signature�I / ' "� �'�� S �(� Dafc 6 ' �"1 'ZU ��f <br /> V <br /> V% <br />