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��Backwater Prevention Device Rebate Program <br />d Rebate Ap�lication Form <br />� <br />��� Property Owner Name: <br />-Lf S �� <br />Installation Address _ � � '-- O _��(�_� � _ — <br />City: �� e rF .� _ State: —��L/r(_ Zip:��j_�7J- � _ . <br />1�lailing Address (if dilierect): ��7� � � l�_P ` v`�-� —__ <br />� n �/ �7 <br />Ciry �/ �-� Slate _ k'/iti ZiP:_��j�r-�� _. _ <br />Email ��G� S_7J �1�/ 'J'7��•_�%1 _ _ Phone: (��� �5�=�� 3 f <br />Total Cosl lo Inslall Device ((rorn contractorinvoice): 5_.(ylti�C{C1_,� _._ <br />Please verify the toliowing: <br />�am the owner o( the property where the back�r�ater prevention device �vas inslalled. <br />� I worked with the conVaclor lo determine the location for the backwater pr?venUon device and <br />understand that the decision regarding the Iocation oi the device �vas rnine. <br />�_� ���Y contracto� inslructed me how to access, inspect, and maintain ihe device. <br />� I understand lhat I am responsible for maintaining the backwaler prevention device and keeping <br />d in good �vorking order, unless it is inslalled in lhe cily righl-of-�vay. <br />❑ If I sell my property, I will make potenlial buyers aware of the backwaler preventior� device and <br />the need �o inspecl and maintaln it on a regular basis <br />�_ � I am enclosiny all o( the nece�sssry pnper::�rn f�.�se ihe yello�:� Reba�a Submittai Checklist). <br />Select from the tollowing: <br />I_ J Thc contractor identitied downspouts or olher drainaye Ihnes Uiat �•rera �,onnected to i,. �.u::er <br />line (beN�cen my house and lhe installed device) and removed, or rerouled Ih�nn <br />❑ To my kno�vledye, my properly has no downspouts or olher dramage conne�h d to my � eveer fine <br />(bet�veen my heuse and the installed device). <br />U There are downspou�s or olher drainage lines conner,ted lo my se�ver linc (br.hveen my houso <br />and the inslalled dr.vir,e�. I unders�and thot I�aving th�se c.>nnecLons creates a risk of fiooding <br />and I ��ccepl lhat risk. <br />l �--� ',' __ - r, i <br />-� � , � <br />Date ' ; .'_ . r ` <br />{ <br />