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Backwater Prevention Device Rebate Program <br />Re6ate Application Form <br />Property Uvmer Narr <br />Insla!latior Address: � O�`t S/ �\I �T')� � �- <br />City: � v�l� State: �_ Zip: C/on20� <br />Ma:ling Address (i(dillarentJ: I3 �% ��i�tril � IU�— <br />City: _�UP�I E'�.- Slale: �'�_ Zip:�pr�U � _ <br />Email� 1'11 5244� �����i1a�• WR° � Phone: (y�jj��3G-6 y�i �{ _ <br />Totaf Cost to Install,Device (Irom contrecfor invoiceJ: $ �%���.�• c� <br />�Plea e verify the following: <br />am the owner of lhe property whera ;he backwater prevention device was installed. <br />���vorked �vith the contractor to deturmine the Iocation for the backwaler prevention device and <br />understand that the decision rega-ding Ihe location o( ihe device was mine. <br />�My contractor inslructed me how •:o access, insp���, and maintain the device. <br />�underst:,nd that I am responsibl� for meintainiry the backwater prevention device and keeping <br />�t in good working order, unless il is installed in the city right-of-way. <br />f I sell m� property, I will ma!�e potentizl b�; ers a�vare of the backwaler prevenfion device and <br />the need lo Inspect and maintain it on a regular basis. <br />[]�I am enclosing alI of ihe necessary paperwork (use the yeilow Rebate Su�mittal Checklist). <br />Select from the following: <br />❑ The contractor identi(ied downs;•�uls or other drai�iage Ilir.es thal v+ere connectvd to rny see�er <br />line (between my house and ih�: installed device) and removed, or rerouled them. <br />❑ To my kno�vledge, my property has no downspouts or olher drainage connec;zd to my sewcr line <br />(between my house and the installed devi:e). <br />� There are downspouts or other dreinage lines connec ted te my sower line (b�lv�een my house <br />' and Ihe installed device). I understand that leaving thase conne.ctions crea4�s a risk of flooding <br />and I accept that risl . <br />I <br />Date <br />