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Backwater Prevention Device Rebate Prog�am <br />Rebate Application Form <br />PropertyOwnerName ���� �-� S�–��L1� �– _— <br />Installatior Address: ��.� U� !�� � �/ � U t <br />Cily: �U-P ��-e�� _8tate' W � <br />Nlading Address (il ddtercnt): _ <br />City: <br />Ema�l: <br />State: <br />Tolal Cost to Inslall Device (Irorn contractor invoiceJ: 5 <br />Plcase verify the following: <br />z�P: `� gz� � <br />Phone: ( ) <br />� 1'Z G�3� -�� <br />� I am the o�vner ot the property v,here the back�vater prevention device v.�as installed. <br />��I �vorked with the contractor to determine lhe localion for the back�vater prevention device �nd <br />undersland that the decision regarding the location of lhe device was mine. <br />j�My contraclor inslrucled me how lo access, inspect, and maintain Ihe device. <br />[�understand that I am responsible for maintaining lhe backwater prevention device ar,C keeping <br />it in good v+orking order, unless it is inslslled in the city right-o(-way. <br />[� If I sell my properly, I will make poteniial buyers a�vare of the back�valer prevenlion device and <br />Ihe need to inspect and mainlain it on a regular basis. <br />�J� I am enr.losiny all of the �.:cessarv papenvork (usc the yellow Rchate Submittal Checklisq <br />Srlect from lhc followirn�: <br />� j The contractor idenlifiec: do�vnspouts or othr,r drainage Ili���s that were connected lo my sewer <br />line (bclween my housc and lhe installed device) and removed,.or rerouted lhem. <br />j7 o my kno�vledge, m�• � mperty has no dow�nspouls or other drainage connecled lo my sewer iine <br />(between rny house and the inslalled device). <br />; j There are downspouts or olher drainage lines connecled to my sewer line (belween rny house <br />and Uie installed device). I understand lhat leawng these connections creates a risk ot flooding <br />and I accept that ns!c. <br />�� � i i <br />Signature� /1�u - ,,l � ;.(� Dafe � � C l I <br />/ <br />\ _- <br />