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Backwater Prevention Device Rebate Program <br /> E„ Rebate Application Form <br /> r'o�'�a���� � ��?,S�R ��� � <br /> Property Owner Name: �� <br /> InstallationAddress: �o�,� � n1�\�� V �Q�� � _ <br /> � City: l JQ�� State: � t'� Zip: `��a�� <br /> � Mailing Address (if dilferenf): � <br /> Cily: State: Zip: <br /> I Email: _ Phone: ( ) <br /> Total Cost to Instali Device (Irom conlracfor invoice): S 'r��G_ —� I <br /> Please verify the following: <br /> � 1 am the owner ol the property where lhe backwater prevention device was installed. <br /> I K� I worked with the contraclor to determine the location for the back�vater prevention device and <br /> ` undersland that the decision regarding the location of lhe device was mme <br /> My contractor inslructed me how to access, inspect, and mainlain lhe device. <br /> I understand that I am responsible for maintaining the backwaler prevention device and keeping <br /> it in good working order, unless il is installed in the city right-of-Svay. <br /> �} if I sell my property, I will make potential buyers aware of the backwaler prevention device and <br /> �; the need to inspect and maintain it on a regular basis. <br /> � I am enclosing all of the necessary papenvork (use the yellow Rebate Submittal Checklist). <br /> Select(rom the following: <br /> �] The conlractor idenlified downspouts or olher drainage Ilines that were connecled to my sewer <br /> line (beh��cen my housc and the inslalled device) and removed, or rerouted Ihem. <br /> [J To my knowledge, my property has no downspouls or other drainage connected lo my sewer line <br /> (b�lween my housc and lhe inslalied device). <br /> �!.}'There are downspouts or other drainage lines connected to my sev+er line (between my house <br /> and Ihe installed device). I undersland that leaving these connections creates a risk of Oooding <br /> and I accept thal risk. <br /> __�. <br /> � ' -�zl�s <br /> Signature Date <br /> � <br /> � _ - - - - -------- -- --- -- -- -- — � - - - — - — <br />