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�^%Q� Backwater Prevention Device Rebate Program <br />Rebate App{ication Form <br />� � <br />i Pr�perty Ovmer Vame � <br />!nstallation AdAress „i ./(�_ i �' `/C . Y C,tCl✓ti <br />. � �l/uZd � I� <br />r�ry �,��(Lr.G-L'� State � �C� Zip <br />'vtailing Address (i(differenQ: <br />Cdy —. _ <br />Lmail <br />State <br />lbtal Cos! ;o Inslall Device (6om conlractor invoiceJ. 5 <br />Please verify the following: <br />Phone ( ) <br />��I am the ov:ner of thc properly v✓here the oackv�ater preventron device �vas installed <br />[7 I e�o�ked vnth the conlractor to determine the location for the back��:ater prevention device and <br />understand ihat the decision regarding Ihe local�on of Ihe device was mine. <br />[�� tJy contractor instrucled me haw to access. inspect, and maintain the device. <br />�( I undr.rsland tnat I am responsibin for maiNaimng the backwalr.r prevenlion device and keeping <br />d m aood working order, unless it is installed in the city riyht-of-�vay. <br />�t:j' '.f I sell my properiy, I e�ill make polenlial Uuyers aware of Ihe back�vater preventior dev�ca antl <br />tne� need'o �nspect and main�afn it on a regular basis. <br />�J I am e�i�ius�ng aU of Ihe necessary uaoen•;o�k !use ihe q��llotv �2et�ate Submdtal Checkhsq. <br />Select from the followmg: <br />� i The cantraclor idenl�hed doc�nspoi�ts or other drainage Ihnes that �vere connectea lo iny sr:ie� <br />line (between rny hause and It�.c rostalled devlcc) and removed, or rerauted Ihem. <br />j�To my kno�vledpe. my property has no c�ovmspnuls or other dramage connecled lo my sev�er line <br />(behveen my house and thc installed device) <br />� � 1 here are do:mspouls or alher drainaqe lines connected to nry se�ver line (belc�een rny house <br />ard !he installed devn,r) I undcrs�and �hal le.�vinq the5r: u�n�ier.hm•s c�reales a nsk nf Iloodm�� <br />and I accepi that nsk <br />� f� <br />/ '� ' � � f� — <br />Signaturc ;'�.�:,.1, �_L/i: - <•- Date -� ,��/l� �v <br />� <br />