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�,�}�► I3ackwater Pre�•ention Device Rebate Program <br />�^�F,.,. �'.ebate Application Form <br />��-- - <br />Property Owner Name: <br />Inslallalion Address: <br />City:��'i' / - State: �,��_ Zip: �� i3 � — <br />A4ailing Address (�(di/(eranQ: <br />City: <br />Email: <br />Slate: <br />Phone: (�'G'�'� S�I.S—!� �/� <br />Total Cosl lo Install Device (from contrac(orinvoice): S__12fSoo.�� <br />Please verify the following: <br />r/1 I am the. owner of the property where the backvrater prevention device was instalicd. <br />i <br />f71 I worked wilh Ihe contractor to determine lhe localior. for the backwater prevention device and <br />�T� understand Ihal the decision regarding the location of the device was mine. <br />� My wnlrar.lor instrucled ma how to access, insp�cl, and maintain lhe device. <br />j�I undersland that I am responsiole for maintaining lhe backwater preventian device and keeping <br />it in good �vorking order, unless it is installed in Ihe city righl-of-�vay. <br />I, �] If I sell my properiy, I w�ll make po�.�ntial buyers aware of the bar.kwater prevention device and <br />� the need to inspect and maiNain it on a regular basis. <br />[rj I am enclosing aIl of the necessary paper.vork (use the yellow Rebale Submitlal Checkllst). <br />Select trom the following: <br />❑ The contraclor idenlified do�vnspouls ur other �rainaye Ilines that were connected lo my sewer <br />line (beiween my house arn�, �he installed device) and removed, or rerouled lhem. <br />�j To my knowledge, my property has naanwnspouts or other drainage connecled to my sewer lino <br />(bolwoen rny house and ihe inslaliod device). <br />❑ There are downspouts orother drainac�e lines connecled to my sewer line (belween my ho�se <br />and the inslalled device). I understand lhat leaving these connections creates a risk of tiooding <br />and I accept that risk. <br />,� � ��' �� � , � �,_ <br />Signafure �%� ���li��'% ��rd'L(%�ic✓ Date � .:��� '-' <br />� �;� ,�� <br />