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Backwater Prevention Device Rebate Program <br />0 Rebate Application Form <br />Property Owner Name: �, , <br />- <br />- <br />Installatio <br />n Address: �'Ir/ �.l V q� <br />City: /� _Q l��( l f State: Zip: <br />Mailing Address (if different). <br />City: State: Zip: <br />Email: <br />Phone: ( <br />Total Cost to Insta't Device (from contractor invoice): $ " <br />Please verity the following: <br />L�J I m the owner of the property where the backwater prevention device was installed. <br />worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />contractor instructed me how to access, inspect, and maintain the device. <br />understand that I am responsible for maintaining the backwater prevention device and keeping <br />zLJ good working order, unless it is installed in the city right-of-way. <br />It I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />EY'lam enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage times that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />5-To my knowledge, my property has no downspouts or other drainage connected to my sewer tine <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />.�J � s <br />Signatur ate �(o' G/'/5 <br />