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Backwater Prevention Device Rebate program <br /> E_, Rebate Application Form <br /> Pioperty Ovmer Name: l 1 c�✓�� �"1<<e-nZ -- <br /> Installation Address: l� � V �L1� �U'V� `�� <br /> City:��� State: �� Zip: �[ Y �–u3 — <br /> I <br /> ��4aiting Address(i(diNerenf): -- – <br /> City: State: Zip: <br /> Email: Phone: (��_:�is �J – 29�i � <br /> � ?� o <br /> Total Cosl to�lnstall Device (/rom contractorinvoice): S 2�' �L��' � <br /> Please verify the following: <br /> [I am the ovrner of the property where the back�valer prevention device was installed. <br /> �worked,with the cantractor to determine the location (or the back�vater prevention device and <br /> undersland that the decision regarding the.location of the device was mine. <br /> Q�y contractor instructed me how to access, in=pect, and maintain lhe device. <br /> �understand that I am responsible for mainta.. :g the back�valer prevention 6avice and keeping <br /> i1 in good working order, unless it is inslalled in the city right-of-way. <br /> � f I sell my property, I will make potential buyers aware o(the backwater prevenlion device and <br /> the nsed to inspect and maintain it on a regular basis. <br /> (�fam enclosing all of lhe necessary paperwork (use the yellow Rebate Submittal Checklisq. <br /> Select irom the following: <br /> [] The contraclor identified downspouts or other drainage Ilines thal were connected lo my sewer <br /> line (betw�en my house and the inslalled device) and removed, or rerouted lhem. <br /> �o my knowledge, my property has no downspouts or olher drainage ronnected to my.sewer line <br /> (behveen my tiouse and�tlie inslalled device). <br /> ❑ There are downspouts or other drainage lines connected to.my sewer line (behveen my house <br /> and Ihe installed device). I understand lhat leaving these connections creates a risk o(flooding <br /> and I accept that risk. <br /> �- � -� 3���� 5� <br /> Signature Date <br />