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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property O�vner Name: �✓�l.tGt i"/(RG �1"A.G�C.✓�J <br /> InstallationAddress: �(0 �� L���� <br /> CV�.�,�' State: IN�" _Zip: 6 0�/ ���7 <br /> City: � - <br /> i <br /> Mailing Address (il diflerent): <br /> City Stale: Zip: <br /> EmaiL bma.eGV'tiGe�CGYl..�7�n�f,/_��am Phone: (�y,(j 2�Z f�_y�_ <br /> Total Cost to Inslall Device ((rom contracfor invoice): 5 Z 7 I�, Q b l Gn ✓o , _ <br /> H <br /> Please verify the following: <br /> �am �he owner oi tlie property wtiere the backwater prevention device was installed. <br /> �worked with the contraclor to delermine the localion for lhe backwater prevention device and <br /> understand that the decision regarding the localion of the device was mine. <br /> [�My contractor inslructed me how to access, inspect, and maintain ihe device. <br /> �I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working ordar, unless it is installed in the city right-of-way. <br /> �I sell my property, I , 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 Rebale Submiltal Checklist). <br /> Select from the following: <br /> �The wntraclor idenlified downspouts or olher drainage Ilines thal were connecled ta my sewer <br /> line (between rny house and lhe installed device) and removed, or rerouted them. <br /> �To my knowledge, my properly has no downspouts or other drainage connected to my sewer line <br /> (between my housc and the installed device). <br /> �] There are downspouls or other drainaye lines connecled to my sevaer line (hetween my house <br /> and the installed device) I understand ihat Ieavin� these conneclions creales a risk of flooding <br /> and I accept that risk. <br /> Signature �` (/""l/'���/��"� Date �� 3 �� <br />