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� Backvrater Prevention Device Rebate Program <br />Rebate Application Form � <br />Property C wner Naine wE/Jl�� �/l�f�"%�.SSQN -- <br />InslallationAddress: %�I7 ��/V�K� D�. <br />Ciry: CV��2� Jj— State: w� Zip: G%'��� <br />Mailing Address (il drfferent�: �/�7V% � <br />City:_ � State: �— ZiP:_.. �— I <br />N � �t ,� n/ L , �!'J7'1�l Phone: �%:1���" ZZ � <br />Emai1: 1 6 /� �. / � �1i�1.4-/ <br />Tota: Cost to Inslall Device (from contractorinvoice): S�'j. ���_`� � <br />Please verify the following: <br />[� I am the o�yner of the property where Ihe backv✓ater prevention device was installed. <br />r I worked with lhe contractor to determine the location for the bactcwater prevention device and <br />understand Ihat Ihe decision regarding the location of Ihe device �vas mine. <br />i <br />�\;{ My contraclor instruGed me how to access; inspect, and maintain ihe device. <br />L�I understand Ihat I am responsibie for maint2 +ing fhe backwater prevention device and keeping <br />It in good aiorking order, unless it is installed in ihe cily nght-of-way. <br />�f I seil my property, I will make potentiai buyers aware oi the backwater prevenlion device and <br />the �ieed �o Inspect and maintain it on a regular basis. <br />j��ani enciosing all of �he necessar� paperwork (use Ihe yellow Rebale Submittal Checklisl). <br />Solect from the following: <br />r� The conlractor identified dovmspouts or olher drainage Ilines thal were connecled to my sewer <br />lin (betwcen my house ond the inslalled device) and removed, or rerouted lhem. <br />To my knowledge, my property has no downspouts or olher drainage connecled to my sewer line <br />(betiveen my house and the inslalled device). <br />(� 7here are dovmspouts nr olher drainage lines connecled to my sewer line (between my house <br />and ihe installed device). I understand Ihai leaving these conneclions creates a risk of (looding <br />and I accept that risk. <br />�'// �Y� �iI Ib / 5 <br />Signatu�� n^�"w�tl{ �Dafe � <br />