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� <br />��%��Backwate� Preventios� Device ftebate Program <br />�, Rebate Application Form <br />Property Owner Nam <br />Installation Address: <br />p 1I <br />City: �_�'t,�CS� . <br />t✓�ailing Address (rl drffoicr,l): _ <br />CAy: <br />Stale <br />Finai� Phone:(`I7S) I'3�a � <br />Total Cost lo Instal� Device (/rom coniraclor invoice): S��._� � <br />i <br />Plcase verify the following: <br />I am tho owner of the property where �he backwaler prevenUon dewce was instelled. <br />i workod wi�h ihe contractor to detertnine ihe lucatlon for tho backwater prevenlion d�,vice and <br />understand Ihat the decision regarcling the localion ol the dewce was mine. <br />iy�l My Wnlractor instrucled me hc�N W acr,ess. inspect, and maintain Ihe device. <br />�I I understand lhat I am �esponsiblo tor mainlaining �he backwater prevention device and keeping <br />it in good working orcJ�r, unless it is instal!cd in tho city nght-of-way. <br />fX-1 I( I sell my property, I will make puten6el buyus aware of tho backwater prevention device and <br />�� ihe need to mspect and maintain it on � regular hasis. <br />� I am endosing all of the necessary paperv+ork (use tho yellow Rebale Submittal Chocklist). <br />Soloct from thc (ollowing: <br />❑ The conlrectnr irienGfiea downspouts or other dramage Ilines Ihal were connecled lo my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />�To my knowledgr., my propeRy has no downspouls or olher drainagA conneded lo my sewer line <br />(between my house and �he installed duvico). <br />[� There are dotimspouts or other drainage lines connected lo my se�ver line (between my house <br />and the installed dr.vice). i undorstand that leaving those connections crP�fes a nsk of Flooding <br />and I accept ihat risk. <br />Slgnafaro . ��DaPe1e�C/��J�__ <br />� 7? <br />