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04LBackwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Names `LI C IIr e C /l rl 5�14 n,�eN S/ M PS Gh <br />Installation Address: <br />City: C (%P JP Slate: W0. Zip: S �/ <br />Mailing Address (if different): <br />City: <br />State: <br />Email: Uc f o_ COM Phone: (4Z5)3_` 3-8N 13 <br />Total Cost to Install Device (horn confractorinvoice): 5-r�(y'� �• S8 <br />Please verify the following: <br />R-ram the owner of the property where the backwater prevention device was installed. <br />[tfworked 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 />Q My contractor instructed me how to access, inspect, and maintain the device. <br />e-iundersland that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />U'lif 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 />PZI am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The 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 />040�-My knowledge, my property has no downspouts 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 />SignafurelLl.C� Cftww— Date <br />