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Backwater Prevention Device Rek,ate Program <br /> Rebate Appl�cation Form <br /> Property Owner Name: /��}'�}�- T/e1��71r� <br /> Inslallation Address: ��a- � �� <br /> City: GV?t�2'� Stale: �_Zip:��,��� <br /> Mailing Address(if diHerenfJ: ��/C l��L�� <br /> City: �/P.Ir2: State:�Zip:_�Q„� <br /> Email:��� I C � _�C�_Phone: (����Gy� <br /> Total Cost to Install Device (from contreclor invoice): S_ <br /> Please verify the foilowing: <br /> [t�l am the owner of the property where the backwater prevention device was installed. <br /> �I worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> � [C�My conlraclor inslructed me how to aocess, insvect, and maintain the device. <br /> � � understand ihat I am responsible for maintaining Ihe backwater prevenlion device and keeping <br /> � it in good working order, untess it is installed in the city ri�ht-of-way. <br /> � [�If I sell my property, I will m�ke potenliai buyers aware of the backwat�r prevention device and <br /> ! the need to inspect and maintain it on a regular basis. <br /> �am enclosing all of lhe necessary paperv�ork (use the yellow Rebate Submittal Checklist). <br /> Select from the followiny: <br /> ❑ The coniraclor identified downspouts or other drainage Ilines lhat were connected to my sewer <br /> line (between my house and lhe ins[alled device)and removed, or rerouled them. <br /> ❑ To my knowiedge, my propeAy has no downspouls or other drainage connected to my sewer line <br /> (betwr.en my house and the installed device). <br /> ❑ There are downspouts or oiher drainage lines connected to my sewer line(between my house <br /> and lhe installed device). I undersland that leaving lhese connections creates a risk of(looding <br /> � and I accept thal risk. <br /> Signator� Date___� <br />