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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />InstallationAddress: _ 7�b 4c"'k <br />City: C Ve rz State: t.AU .A <br />Mailing Address if different): �� 10 19 �- ✓�. j�N a-C�h <br />City: �1�2t� State: UJA r <br />�} ff Zip:_l�d7{0 <br />Email: r Ir,>vH_ Phune: <br />Total Cost to Install Device (from contractor invoice): S <br />Please verity the following: Ole k N N^')�CM O `^a' /ZJ'170 <br />fk, rw 11-1-S477 <br />l� I am the owner of the property where the backwater prevention device was installed. �'~ '` a'✓' . <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, rt �f aft r <br />My contractor instructed me how to access, inspect, and maintain the device. <br />�1 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 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 It ,ny sewer line <br />(between my house and the insta!'od 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 />S/gnatuream L � Date <br />