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�^%��Backwater Prevention Devics Rebate Program <br />d Rebate Application Forn� <br />-- -- — -- <br />Property Owner Name: ___�,���J�/J/ <br />Installantion Address. ��_ ��S_� <br />City: ��'��-- State: —�,(/ !'� _- —_ Zip: y�a_� l j <br />htailing Address (il diL` �e t): __�_ ��� / 3�� <br />Cily ���,{�(��� L-� (,l:.� State: _ W_�__ Zip' 9 a o�� <br />Email:��,���1(� lOr : �S _Ifmtl�,� , � )1'� _ Phone: (y� ) �1J � � "I �� ' <br />Tolal Cosl lo install Oevice (from cont2ctorinvoice): $.__ <br />Please verify the following: <br />� I am the oamer of lhe property where the backwater prevenlion device v�as installed. <br />❑ I�vorked with Ihe confrador to delermine fhe location for the bar.kwater prevention device and <br />understand ihat the decision regarding the localion of the device was mine. <br />❑ My contractor irstructed me how ro access, inspect, and maintain fhe device. <br />� I undersfand tha� I am responsible (or mainlaininy (he bar.kwaler prevention device and keeping <br />il in good working order, unles� il is installed in the cily righl-of-way. <br />❑ If I sell my propeRy, I will make polential buyers aware of the backv�ater prevenlion device and <br />ihe need to inspecl and mainlain it on a regular basis. <br />[] I am enclosing all of the necessary papenvork (use the yellow Rebate S�ibmitlal Cher,klist�. <br />Select from the following: <br />U The contractor idenlitied downspouts or olher drainage Ilinas that were connected to my se�ver <br />line (belween my house and lhe inslalled device) and removed, or rerouted them. <br />❑ To my knowledge, my property has no downspouls cr olher drainage connected lo my sevrer line <br />(belween my house snd lhe inslalied device). <br />(—J There are downspouls or olher drainage lines connected to my sewer line (belween my houso <br />and the ins�alled device). I undersland Ihal leaving lhese conneclions creates a risk of flooding <br />and I accept that risk. <br />Signatur ____. <br />Date ���_ �` <br />