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4d Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: 1 UL/C�.m q C% / ALd�r] kL- sir r Thy <br />Installation Address: -2,S/20 1 rnSA40 4z . <br />City: C-VeY/--Zz State: /.A- Zip: ( <br />Mailing Address (if different): <br />City: Stale: Zip: <br />Email: Phone: ( ) <br />Total Cost to Install Device (from contractor invoice): $ -', <br />Please verify the following: <br />[� I am the owner of the property where the backwater prevention device was installed. <br />1 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 />[� My contractor instructed me how to access, inspect, and maintain the device. <br />I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />YIf I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />`KI am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts 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 />MU Tu my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the Installed device). I understand that leaving Uiese conneclions creates a risk of flooding <br />and I accept that risk. <br />Signature// iL Date <br />