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Backwater Prevention Device Rebate Program <br /> E Rebate Application Form <br /> Property O�vner Name: ��"'r�v /'��� �I <br /> /q i <br /> Installation Address:_�L__/ �'� �"� ��/� — <br /> � �� � �,��-_ ��—� �za <br /> City' �_«=r'�� State: Zip: _ <br /> Mailing Address (if difre�ent): ��l ��"c � _ <br /> City: State: Zip:_ <br /> Email: _ .____ _ Phone: ( )_ _ <br /> Total Cost to Inslall Device ((rom contracforinvoice): 5 <br /> Please verify the following: <br /> �am lhe owner of the property where the backwater prevention device was installed. <br /> '� vorked wilh the conlractor to determine the location for the backwater prevenl��n device and <br /> undersland tnat the decisicn regarding the location o(the device was mine. <br /> �G `tvt;i contrac�oi instructed me hor� fo access, inspect, and maintain the device. <br /> � l <br /> undersland that I am responsib�e (or maintaining the backwater prevention device and keeping <br /> ' it i good working order, unless itis insta�led in the city nght-of-way. <br /> -f�r�Ll sell my property. I will make polential.buyers aware of lhe backwater prevention device and <br /> �� th�,eed to inspect and maintain it on a regular basis. <br /> ❑ I am enclosing all oi the necessary paperwork (use the yellow Rebate Submittal Checklist) <br /> Select from the following: <br /> �J The conlractor idenlified downspouls or other drainage Ilines that were connected to my sewer <br /> line (between my house and the installed device) and removed, or rerouted them. <br /> � To my knowledye, my property has no downspouls or osher drainage con�iected to my sewer line <br /> (between my house and lhe inslalled device). <br /> ❑ There are downspouts or olher drainage lines connecled to my sewer line (behveen my house <br /> and the installed device). I understand that leaving these connections creates a risk of tlooding <br /> and I accept Ihal risk. <br /> � <br /> ' natu , Date� ��� <br /> �-- ----- ----- ----- ---- — - - -- -- -- .. - - --- - <br />