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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> PropertyOwnerName: ��{��� ���5 <br /> Installation Address:�j��� � rl�• <br /> City� �K-E['� State:�_Zip: �ZO� <br /> Mailing Address(if diHerent):�,_� <br /> Ciry:_ __ State: Zip: <br /> Emaii: ��IQV_l�_.�..�.�lL� ��1L. (�� phone: �73j 345�4Z89 <br /> Total Cost to Install Device ((rom confractorinvoice): $_0��3� - �� <br /> Piease verify the following: <br /> �I am the owner of lhe property where the backwater prevention device was installed. <br /> � I worked with ihe coNractor to delermi;ie the location for the backwater prevention device and <br /> understand lhat the decision regardirig the localion of the device was mine. <br /> �My conlractor instructed me how to access, inspect, and maintain the device. <br /> � I understand that I am responsible tor maintaining the backwaler prevenlion device and keeping <br /> it in good working order, �:nless it is installed in ihe city right-of-way. <br /> � II I sell my property, I will make polential buyers aware of lhe backwater prevention device and <br /> the need to inspecl and maintain it on a regular basis. <br /> �I am enclosing all of the necessary paperwork (use ihe yellow Re6ate Submittal Checklist). <br /> Select(rom the following: <br /> ❑ The c.nntractor identi(ied downspouts or other drainage Ilines that were connected lo my sewer <br /> line (between my house and lhe installed device)'and removed, or rerou:Pd them. <br /> ❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer Ilne <br /> (between my hause and the installed device). <br /> /� There are downspouts or olher drainage lines connecled lo my sewer line(belween my house <br /> and the inslalled device). I understand ihat leaving these connections creates a risk oi flooding <br /> and I accept that risk. <br /> Signature _� Date y ZS�/.S <br />