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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: �� r r N�`�'�� 5 <br />Installation Address: .3 �� 3 Lo.�n t��-+L� u���� <br />City: �VL�QCrT State: w� • Zip: �%�201 <br />P4ailing Address (ifdi((erentJ: 29oS I C+ f� SY <br />City: L VLrn�'T'f" State: �� � Zip: `�8 ZO j <br />Email: Sawha�z2�S' ���Nno . Cc��� Phone: (4� 341Q -fa 137 <br />Total Cost to Install Device (f�om contractorinvoice): $ �-`{�2 •�3 <br />Please verify the following: <br />�' I am the owner of the property where lhe backviater prevention device was installed. <br />� I worked wilh the contractor to determine the loizticn `or the backwater preve�ition device and <br />understand that the decision regarding the location o! the device was inine. <br />�j �y contractor instructed me how to access, inspect, and maintain the device. <br />0 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-wa;�. <br />Q If I sell my property, I will make polential buyers aware of ihe backvaater prevention device and <br />the need to inspect and mainlain it on a regular basis. <br />� I am enclosing all of fhe necessary paperv�ork (use the yellow Rebate Subinittal Checklist). <br />Select from the following: <br />(�j The contractor identifed downspouts or other drainage Ilines that were connected to my sewer <br />line (between my house and lhe installed device) and removed, or rerouted them. <br />� 1'o my knowledge, my property has no downspouts or other drainage connected lo my sevoer line <br />(behveen 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 these connections creates a risk of ilooding <br />and I accept that risk. <br />SignaWre /I.��°" a- �r� Date �'" �� '� <br />