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. , i <br /> �,�}� Backwater Prevention Device Rebate Program <br /> ^��1 Rebate Appiication Form <br /> N/,�,�„ <br /> ._� <br /> Property Owner Name:� � e� <br /> � <br /> Installation Address: �� �3� ��.^�7�''�� �"'L- <br /> City: �;�'�- __S:ate: �� Lip:��'� � <br /> Mailing Address (ifdiNerent): �_ -r1i� <br /> City:__ State: Zip:. <br /> � �- u,1'd-- te�'�-�a <br /> Email: YC,�oc.I e-�kjc.� '1[d q� ' � •�^ Phone: (cJaw___ ' <br /> ITotal Cosl to Install Device(Imm confrac(or invoi:e): 3 — <br /> Please verify the following: <br /> �am the owner oF the property where the bach,�ater prcventlon device was installed. <br /> ��a�orked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of!he device.was mine. <br /> [v�My contractor instructed me how to access, inspect, and maintain the device. <br /> � undersiand that I am resFonsible for maintaining the backwater prevention de�ice and keeping <br /> it in good working order, unless it is installed in lhe city right-of-way. <br /> �If I sell my property, I w•ill make po�enlial buyers aware of the backwater prevention device and � <br /> the need to inspect and maintain it on a regular basis. k <br /> [�am enclosinq al! of lhe nece,sary pzperwork(use the yellow Rebate Suhmittal Checklist). � <br /> i <br /> Select from the following: ' <br /> �The contractor identified downspouts or other drainage Ilines that were connected to ny� :u:�ver � <br /> line(betwcen my house and Ihe installed device)and removed, or rerouted lhem. : <br /> []j To my knowledge, my property has no downspouls or olher drainage connected to my sev✓er line ` � <br /> (belween my hocse and the installed device). i <br /> �`� ❑ There are downspouts or other drainage lines comected to my sewer line(between my house I <br /> \ and the inslalled device). I ur,derstand lhat leaving these connections creales a risk of Flooding <br /> a, i I acceot lhat risk. I <br /> Signature_�_ �Date ����y/�_ <br /> I <br />