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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: �A.+/r�.�C Wl �S �-� C—rVL�2�-� <br />Installation Address i`� Z�-{ ��ll ����4 wl 1 �4.V C <br />City: ��pST?'- Stale: C.c�� Zip: �52C� � <br />Mailing Address (if diHerent): AS�S �i�� A�.A.� ��lA l3 ��J ( <br />Cily: �G-v�YT-` State: (�� 1A Zip: `�Fs 2� f <br />Email: ' Phone: (�Z5 ) %�-ri � - -�`� � <br />Total Cost lo Install Device (from contractorinvoice): $ 2-,SD�'� <br />Piease verify the following: <br />g( I am the owner �f the property whe� � fhe backwater prevention device was installed. <br />�' I worked with the contractor to determine the locatio� for the backwater prevention dew�e and <br />understand that the decision regarding the location of the device was mine. <br />� My contractor instructed me how to ar.cess, inspect, and maintain the device. <br />� I understand that I am responsible for maintaining the backwater prevention device a�d keeping <br />it in good working order, uniess it is installed in the city right-of-way. <br />� If I sell my Nroperty, I will make potentiai buyers aware of the backwater prevention device and <br />the need to mspect and maintain it on a regular oasis. <br />[� I am enclosing all of the necessary paperw�rk (use the yellow Rebate Submittal Checklist). <br />Select from the tollowing: <br />❑ The contraclor identitied downspouts or olher drainage Ilines lhat were connected to my sewer <br />line (between my house and lhe inslalled device) and removed, or rerouted them. <br />�' To my knowledge, my property i.�s no downspouls or othet drainage connected to my sower line <br />(between my house and lhe instalied device). <br />❑ There are downspouls or other drainage lines connecled to my sewer line (belween my house <br />and the installed device). I understand that leaving these connections creales a risk of flooding <br />and I accept thal risk. <br />�f << ; <br />Slgnatu Date 1 l - •� � ' � `f <br />