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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owne�Name: �A..�tJ�G�� ���'� <br /> Inslallation Address: ���� �,r'� 1 � � ��� � <br /> ` C.{ l I <br /> City� e-� '� State: �^1.�� � Zip: 1,��� <br /> ,,r DK. . <br /> MailinyAudress(ifdiNerenf)�_ I `� �n %�R� V� EVT� W/�, q�Za � <br /> City: �r� State: W /k-_��IP� � 8 2c�3 <br /> Email:IGl-� Y/�T'���}l�'GD��Gc�`7 i 'n�� Phone: �j��.� —`..� ��j Cl <br /> Total Cost to Install Device ((rom contractor invoice): $ �✓���� _ <br /> Please verify the fallowing: <br /> ,� I am lhe 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 /> u derstand that lhe decision regarding tho location o(1he device was mine. <br /> Mry contractor instrucled me how to access, inspect, and maintain the device. <br /> I undersland that I am ��sponsible for maintaining the back�vater prevenlion device and keeping <br /> it in gnod working order, unless it is installed in the ciry right-of-way. j�„� <br /> � If 1 sell my property, I will make polential buyers aware ot the backwater prevention device and <br /> the need to �nspect and mainta�n it on a regular basis. <br /> J] I am enclosing all oi the necessary paperwork (use the yellow Rebate Submittal Checktist). <br /> J � <br /> �t, Select from the tollowing: <br /> p��'� • The contraclor identified duwnspouls or other drainage Ilines that were connected lo my sewer <br /> � �line (between my house and Ihe installed device)and removed, or:erouted them. <br /> �,I� (7�To my knowledge, my property has no downspouts or olher drainage connected ro my sewer line <br /> �.j' l (between my house and the instalied device). <br /> �� � There are downspouts or olher drainage lines connected to my sewer line(between my house <br /> and the installed device). I undersland that leaving these connections creates a risk of Oooding <br /> and I accept that risk. <br /> / <br /> C�1�� <br /> Signature_ Date � � � <br />