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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Nan <br />Installation Address: <br />City: _�rrlLrld— Slate: l,U 7 Zip1_ <br />Mailing Address (if different). <br />City: <br />Email: <br />State: <br />Zip' <br />Phone: (aip) a5 ( 3'b ( <br />Total Cost to Install Device (from contractor invoice): $ 9- -f of et • s-o <br />Please verify the following: <br />VL/ l m the owner of the property where the backwater prevention device was installed. <br />worked with the contractor to determine the location for the backwater prevention device and <br />rstand that the decision regarding the location of the device was mine. <br />V/contractor instructed me how to access, inspect, and maintain the device, <br />understand that I am responsible for maintaining the backwater prevention device and keeping <br />;;I,fgood working order, unless it is installed in the city right-of-way. <br />-41s <br />tII my property, I will make potential buyers aware of the backwater prevention device anpd <br />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 Hines 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 ininage connected to my sewer line <br />/(between my house and the installed device). <br />drLl 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 />Slgnaturo v' Date r/ ys <br />