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�Backwater Prevention Device Rebate Program <br />Q, Rebate Application Form <br />(--- <br />PropeAy O�vner Name: �� y �/l� �.Jj�Es�� _ <br />Installation Address: �yr� ��`��R� _..l��� <br />Cify: _' U�l� %T Slale:..�l �_ __ lip 90 ZO� <br />tvlailing Address (iI diNerent): _ �� �?.S ✓�✓� 2% <br />Cily: �VjiL-�[ Stale: (/VY9—" Zip:���� <br />v .; <br />Email: _ <br />Phone ( � —' �� ��� �� <br />Total Cost to Install Device (Irom contractor invoice): 5 2� .Se�G i <br />Please verify the following: <br />I� I am ihe o�vner of the property where ihe backvlater p� evenlion device �vas ins�alled. <br />�T7� I worked with the contractor to delermine the localion for the backwater prevenlion devic� and <br />�F � undersland that the decision regarding the location of lhe device was mine. <br />�I� fvly contraclor instructed me how lo access, inspect, and mainlain lhe device. <br />� I underslznd �hat I am responsible for mainlaining the backwater pmvention device and keeping <br />d in good working order, unless il is installed in the ciry right-of-�vay. <br />�If I sell my property, I v�ill make potential buyers aware of lhe backwater preventinn device and <br />the need lo inspect and maintain il on a regular basis. <br />� I am enclosing aIl of Ihe necessary papenvork (use the yellow Rebale SubmiUal ChecklisQ. <br />Select (rom ihe following: <br />�] The contractor idenlified dovmspouls or olher drainage Ilines Uiat v+ere connected to my see�er <br />line (belwecn my house and lhe mstalled device) and removed, or rerouted them <br />{� To my knowledge, my property has no dolvnspouts or other drainage connecled lo my sewer line <br />��(belween my house and the inslalled device). <br />[j There are doe+nspouts or olher drainage lines connected to my se�ver line (between my house <br />and the installed device). I understand thal leaving Ihese connection� creales a risk of (looding <br />and I ar.cepl fhat risk. <br />9 <br />Signature ��2 � ���W� Date ? �S � �� <br />i ! <br />� <br />