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Backwater Prevention Device Rebate Program <br /> Rebate Applic�ation Form <br /> PropeRy O�vner Name: ,h;SR..V1 � �C�- _ <br /> Inslallation Address' ��r 7 �� <br /> City: ✓�� _ �_ State' � � Zip: �t O�U1 I <br /> Mailing Addres, (il dilferenQ� I <br /> City: State: Zip: _ <br /> Email:�nP ' -lmC=�.�vr���t/_4�_—_ Phone: (SU3)�"�,YJ$._ <br /> Total Cost lo Inslall Device (from contractorinvoice): 5 �.SGC. �� __. <br /> Please verify the following: � <br /> �"I am the owner of the property �vhere the backwater prevention device was installed. <br /> [}� I �vorked with the contractor to determine lhc locaiion for the backwater prevention decice ar�d I <br /> undersland tha! Ihe deci;ion regatdiny the location of the device�vas mine. <br /> ,� My conlraclor insiructed me how to access, ins�ect, and mainlain the device. I <br /> ;�' I understand Ihat I am responsible lor main�ain�„� Il�e backwaler prevention device and keeping <br /> it in good wo�hing order, unlass it is mst..11ed in the city right-o(-way. <br /> �If I sell my prcperry, I v�ill make potenfial buyei s aware of the backwater pravanlion device and <br /> the need to inspect and mainlain it on a regular basis. <br /> ,� I am enclosing al� of the necessary paperwork (use the yellav Rebale Submittal Checklisl). <br /> Select from the following: <br /> � The contracror identitir.d do�vnspouls or other drainage Ilines ihat .vere connected to my sewer <br /> line (behveen my house and lhe inslalled device)and removed, or i�routed them. <br /> � To my knowl�dge, my property has no dovmspouts or olher drainage connecled to my se�ver line <br /> (be6veen my house and lhe installed device). <br /> (] There are downspouls or olher drainage lines connecled to my sewer line (behveen my house <br /> and lhe installed device). I understand thal leaving ihese connec6ons creates a risk of Oooding <br /> and I accept that risk. <br /> Signature� ��--- Date � � �� � �S <br /> �� <br /> '�---- -- --- -- _� . <br />