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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property O��mer Name: <br />Inst�lla?ion Address: �-I G Z mC-�G1��� � <br />City: ��/eS�T State: � RF� � Lp: ��'� I _ <br />Mailing Address (ildi((erenl): <br />City: <br />State: <br />Zip' <br />Email: �4l'YlY1I�'C.-L"'�__ �►'�� U���ne: <br />Totai Cost to Install �evice (�rom contraclor invorce): 5_ ___ <br />Please verify the following: <br />, a���-2� � <br />[i/fam the owner of the property where the hackv�ater prevr.nticn device w.as instai'ed. <br />��vorked with the contractor to determine the location for the backwater prevention dev cz and <br />understand that the decision regarding the location of the device was mine. <br />�iYk1y contraclor instructed me how lo access, inspect, and mairdain the device. <br />L�ndersland that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is in: tailed in the city right-of-a�ay. <br />[,iV(rl sell my property, I�a�ll make potenlial buyers aware of the bar.kwatcr prevention devicc and <br />�� the need to inspecl and maintain It on a regular basis. <br />II Vj� 'f am enGosing all of the necessary papenvork (use the yello�v Rebale Sebmittal Checkli�l). <br />�1C <br />Select from the tollowing: <br />U The contraclor identified du�vnspouls or other diain� ge Ilines that were connected to my se�ver <br />line (belween my hcuse and Uie inslalled devica) and removed, or rerouled �hem. <br />! io my knowledge, my properly has no davnspouts or other drainage connected ln my sewer linc <br />(behveen rny house and lhe installed device). <br />❑ There ars downspouts or o�her drainage lines connecled to my sewer Iine (bele�een my house <br />and the inslalled devicej. I undersland Ihal leaviny these wnnections creales a risk of Oooding <br />and I accepl that risk. <br />�li � <br />���. <br />Signature % _ Datc ` (. �l <br />