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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: /% G G A/�/ /— D S% E� <br />Inslailation Address: ,�g z�' %�'1 G QrJ U 6%� L'= i�vC <br />City: �//.�'R F T% State: \/�/ %� Zip: ��i �.B l <br />Mailing Address (ifdiffe�enf): <br />City: <br />Email: <br />Slate: <br />Phone: ( <br />Total Cost to Install Device (from contractor invoiceJ: $ nl �T �� •� <br />Please verify the fotlowing: <br />[� i am the owner of the property where the backwater prevention device was installed. <br />j�] I v�orked with the contractor to determine the location for the backwater prevention device and <br />%� understand that the decision regarding lhe location of the device was mine. <br />�My contraclor instructed me how to �ccess, inspect, and maintain the device. ' <br />I understand that I am responsible fo. maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the cily right-of-way. <br />�jJ If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />] lhe need to inspect and maintain it on a regular basis. <br />❑ I am enclosing all�of lhe necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Selectfrom the foliowing: <br />❑ The coniractor 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 conriected to my sewer line <br />(belween my house and the installed device). <br />❑ There are downspouts or other drainage iines 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 lhat risk. . <br />Signature /X�`� � '"� � Date � � <br />