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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: --P�cxz .P-7 (Tq. >-� ` , <br />Installation Address: aL <br />City: Ezra 2_= State: V�J Ak Zip: gp)i�01 <br />Mailing Address (if different). <br />City: State: Zip: <br />Email: Phone: ( ) <br />Total Cost to Install Device (from contractor invoice): $ -_ <br />Please verity the following: <br />91 am the owner of the property where the backwater prevention device was installed. <br />7� 1 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 />j My contractor instructed me how to access, inspect, and maintain the device. <br />I understand that I am responsibl,.'or maintaining the backwater prevention device and keeping <br />it in good working order, un!ess it is installed in the cit,, right-of-way. <br />If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />he need to inspect and maintain it on a regular basis. <br />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 (lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />❑ To 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 sever tine (between my house <br />and the installed device). 1 understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature <br />