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Backwater F'revention Device Rebate Program <br /> Rebate Application Form <br /> Property Owne, Name:�Q�vt� [i 0.`�9 a�o1 <br /> Installation Address: 2:S l� (�-t�4'.. �''r <br /> City:�U-QK� State: �� Zip: 7�� <br /> Mailing Address(if d'd/enjni): <br /> City: utate: Zip: <br /> Ernail:_�,o • �1 q�RR✓YY� �'�')�u� . (.i4�t Phone: (;7z(tJ 78(a-- al 97 <br /> 3U �Tutal Cost to Install Cavice(fmm contraclorinvoice):$_,�y� �I � <br /> Please verify the following: I <br /> � i�m the o�vner of the property where the backwater prevenlion device was installed. <br /> �rked with the conUactor lo detartnine the locatlon for the backwater prevention devico and � <br /> un rstand that the decision regarding the location of the device was mine. <br /> My contraclor inshuctad me how to access,inspect,and maintain the device. <br /> �nderstand that I am responsible for rnainhaining the backwater prevention device and keeping <br /> il in good working o�der, uniess it Is insialled in the city right-of-way. <br /> � sell my property,I will make potential buyers aware of the backwater preventlon device and � <br /> the need to(nspect and maintain it on a reguiar basis. � <br /> ❑ I am enclosing all of the necessary paperwork(use the yeltow Rebate Submittal Checklist). � <br /> Select from the following: I <br /> fhe contractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> { <br /> line(between my house and the installed device)and removed,or rerouted lhem. � <br /> ❑ To my knowledge, my property has no downspouts or other drainage connecled fo my sewer line <br /> (behveen my house and the inslalled device). � <br /> ❑ There are downspouts or other drainege lines connecfed to my sewer line (between my house � <br /> and the installed device). I understand lhat leaving these connections creates a risk of ilooding <br /> and I eccept that risk. <br /> Signa u 7 . � v' ` - Date /•- ��'-/j— <br />