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4 Backwater Prevention Device Rebate Program <br />Wrr Rebate Application Form <br />Property Owner Name: S qMCI r11 Ca%iQh'1Tf <br />Installation Address: j(0I2 M c <br />City: �4-t'T'i- Stale: A � zip: 61 <br />Mailing Address (if different): <br />City: Slate: Zip: <br />Email:,5ah�n�—�l/�f� %lc7{ h'Uza�• 00� Phone: U53) 2z--5 • $'cl i <br />Total Cost to Install Device (from contractor invoice): $ <br />I <br />Please verify the following: <br />I am the owner of the property where the backwater prevention device was installed. <br />D-<Worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />iD- Ivly contractor instructed me how to access, inspect, and maintain the device. <br />I understand that I am responsible for maintaining the backwater nravention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />Rffhe contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />0-*'To my knowledge, my property has no da mspouts or other drainage connected to my sewer line <br />(between 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 flooding <br />and I accept that risk. <br />sfgna!u� Date ) S <br />