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Backwater Prevention Device Rebate Pro�ram <br />R�bate ApplicatioR Form <br />Property Owner Name: <br />Ir.slallation Address: �Z�����—l.-�r— 1 1 �'C <br />City: V-�V� Stale:_�Zip: /� � 1 <br />Mailing Address (if diBer2nt): _� �V_���T � __ _ <br />City: �_�C�— Slate: �,. � Zi�: �� I <br />Email: �►'F'�21�1 C�,OG�/�( �' �� /��- � Phone: ( ) <br />u <br />Tolal Cost to Install Devix :from contractorinvoice): $ ��it��y� �-- <br />Please verify the followir�g: <br />(�Tm the owner oi the property where lhe backwater prevenUon device vras inslalled. <br />[t� �orked witli the contractor to detertnine the location for lhe bacfcwatar prevention device and <br />understand that ihe decision regaMing the loca�on of the device was mine. <br />[��conhaclor inslruGed me how to access, inspecl, and maintain the device. <br />[]]�f�understand that I am responsibie for maintaining tte backvrater prevention devlce and keeping <br />it in good worfcing order, unless it is inslalled in lhe city right-of-way. <br />[jj�lf I sell my property, I will make potential buyers aware of Ihe backwater prevention device and <br />the need to inspec[ and maintain il on a regular basis. <br />{�m enclosing all oi the necessary paperwork (use lhe yellow Rebate Submltlal Checklist). <br />Seloct (rom thn following: <br />❑ The r,onlraclor identified downspouls or other drainaye Ilines that were conneded to my sewer <br />line (betwecrtmy house and the installed device) and removed, or rerouted Ihem. <br />��I o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(befween my house and the inslalled device!. <br />�J There are dovmspouts or other draie��� !�nes connected to my sewer line (behveen my house <br />and the installed device). I understand that leaving thcsc connections creales a nc' ,( flooding <br />and I accept lhat risk. <br />, <br />Slgnature � Date � _ <br />