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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: (/7 r C I�rn_ <br />Installation A.idiess: _1 <br />dd-"�S'rc �l r • ` 'It f r v <br />City: ��.� �# State: LC, --- <br />Mailing Address (if dlfforent): <br />City: <br />Email <br />State: <br />Phone: <br />Total Cost to Install Device (from contractor invoice} r I.'/ 5=1-_ L' <br />Please verify the following: <br />+' 1 am the owner of the propery where the backwater p;avention device was installed. <br />[.� I worked with the contractor to determine the location for die backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />( v] My contractor instructed me how to access, inspect, and maintain the device. <br />(;3"I understand 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 />If I sell my property, I will make potential buyers aware of g.o backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />( I am enclosing all of the necessary papetwork (use file yellow Rebatu Submittal Checkiir.). <br />Select from the following: <br />VI,- contractor identified downspouts or other drainage Ilinos that wem connected to my sewer <br />line (between my house and the inst,^.11ed device) and removed, or toroutad them. <br />To my knowledge, my property has no downspouts or older drainage connected tc my sewer Idle <br />(halwnen my house: and the installed device). <br />(-] ihere are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving those connections creates a risk of flooding <br />and I accept that risk. <br />Signature ?' �� 6494 - /— y—• S <br />