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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: V i GfDha 941'at( <br />Installation Address: t l t U c/( <br />li City: vP/e—*7— State: <br />Mailing Address (if different): <br />City: <br />State: <br />Zip: i8� I <br />Email: LOf- @ Phone: <br />Total Cost to Install Device (from contractor invoice): $ o oo • 4 <br />Please verify the following: <br />[ I am the owner of the property where the backwater prevention device was installed. <br />] 1 worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding lne location of the device was mine. <br />J4 My contractor instructed me how to access, inspect, and maintain the device. <br />I understand that l am responsible for mointaining 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 the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />1 am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />Wj The contractor identified downspouts or other drainage (lines it.at were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />(v- To my knowledge, my property has no downspouts or other drainage ronnecled 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). 1 understand that leaving these connections creates a risk of flooding <br />and 1 accept that risk. <br />(Signature Date <br />