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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Proper. • Owner Name: <br />Instailation Acidress: <br />City:� <br />t�lailing Address (ildil(erent): <br />! City: _ _ State: Zip _ <br />[maiL _ Ph�e: �3 - /�T�a%1 �% <br />To!al Cost to Install Device (lrom confractor invoiceJ: ���._� <br />i <br />Plcase verify the following: <br />1�1 I am the o�vner ot the property where the backwater prevention device e�as inslalted. <br />—� <br />`�I I workeu .•�ith the contractor to determine the location for the backwater prevention device and <br />��nderstand that the decision regarding the location of the device was mine. <br />�R4y cen,ractor �nslructed me how lo access, �nspect, and main'ain the de��ice. <br />�I understand that I am responsible for maintaining the b2clewater prevention device and keeping <br />it in good �vorking order, unless it is installed in the city right-of-way. <br />�� If I scll my property, I will make potenlial buyers avaare of the back�vater prevention device and <br />Ihe need to inspect and mlinta.in it on a regular basis. <br />��I am enclasing all of the necessary paperv�orlc (use the yellow Rebale S�hm�ttal Checklisl). <br />Sclect trom Ihe lollowing: <br />[ j Thr. eoniraclor identified downs�oids or nlher drainage Iline, tLal �•+eie wnnecled lo my sewer <br />line (between my hnuse and Ihe insta�led device) and remo��ed, or rerouted Ihem. � <br />� To my knowledye, my properly has no downspouts or other drainage connected to my se�•�er hnc <br />(belween my house and the installed de�iice). <br />u Thcre are downspouts or other drainage �ines connected to my sewer line (belween my house <br />and �he installed device). I understand Ihal leaving Ihe,e connections creales a risk ol Ilooding <br />and I accept �hal rislc. <br />„�� �� /.�� �� z.� . �� -_ <br />Signaf 'G�---f_� l Date — <br />t _. <br />