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44Backwater Prevention Device Rebate Program <br />FTT Rebate Application Form <br />Property Owner Name: 0 ice' )L�g _ __ <br />Installation Address: <br />City: �SLj Ctz�--f Stale: tL►—Zip: C `L.2� <br />Mailing Address (if different): <br />City: <br />Email: <br />State: Zip: <br />Phone:( <br />Total Cost to Install Device (from contractor invoice): $4��- gb� <br />Please verify the following: <br />V 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 the location of the device was mine. <br />�d My contractor instructed me how to access, inspect, and maintain the device. <br />(� I understand that I am responsible for rraintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />It 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 />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 />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 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 />Signal! frj�ce� �,U ti c c [v a Date <br />