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%' Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation <br />�Anddress: _ <br />City: _ i/VlX1l <br />Mailing Address (if different): <br />City: <br />Emai;: <br />State: <br />Phone: <br />Total Cost to Install Device (from contractor invoice): $ 4_�t%% <br />Please, verily the following: <br />N I am the owner of the properly where the backwater prevention device was installed. <br />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 mine. <br />Cj, My contractor instructed me how to access, inspect, and maintain the device. <br />`Q I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it rn 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 />'RTo 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 sk of flooding <br />and I accept that risk. <br />Sign e l�=^-� Date <br />