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4--Backwater Prevention Device Rebate Program <br />rr Rebate Application Form <br />Properly Owner Name: <br />Installation Address: 5 `7 7 l/1 _ <br />City: le State:/Zip: <br />Mailing Address (if different): <br />City: <br />State: <br />Email: Phone: (Y.c�o='a <br />Total Cost to Install Device (from contractor invoice): $ <br />Please verify the following: <br />y� I am the owner of the property where the backwater prevention device was installed. <br />FA I 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 jnine. <br />My contractor instructed me how to access, inspect, and maintain the devics:. <br />.I understand tha f l am responsible for maintaining the backwater prevention device and keeping <br />it in coca working order, unless it is installed in the city right'of-way. <br />if I sell my properly, 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 />I am 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 (lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them.:' <br />To my knowledge, my property has no downspouts or other drainage connected to my sewer line <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 />I L <br />I <br />Signature Date ✓��� <br />i <br />i <br />