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., <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Properly Owner Name: _f,>e.q.� �-aw���.'�' <br /> Inslallation Address: � �b � 00.�e s i�e- . __ <br /> Ciry: Lvcrz.� _State: WH zip: `BLoJ <br /> Mailing Address(if di(ferent): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (from conlractorinvoice): 5 �� SoC� <br /> Please verify the (ollowing: <br /> � i am the owner of lhe property where the backwater prevention device was installed. <br /> [� I worked with the contractor to determine the location tor the backwater prevention device and <br /> understand ihal the decision regarding the location oi the device was mine. <br /> � My contractor inslructed me how to access, inspecl, and maintai.• Ihe device. • <br /> (�J I understand thal I am responsible for.maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the cily righl-ot-way. <br /> [7� If I sell my property, I will make potenlial buyers aware of the back�vater prevention device and <br /> the need to inspecl and maintain il on a regular basis. <br /> [� I am enclosing all of the necessary paperwo:K (use the yello�v Rebale Submitlal Checklist). <br /> Select from the following: <br /> [%� The conlractor identiGed downspoitls or other drainage Ilines that were connected ro my sewer <br /> li�e (between my house and Ihe installed davice) and removed, or rerouted Ihem. <br /> [Jf To my knowledye, my property has no downspo�ds or olher drainage connecled lo my sewer line <br /> (belwcen my house and Ihe inslalled device). <br /> �There are downspouls or other drainage lines connected to my sewer line (belween my house <br /> and the installed device). I unJerstand lhal leaving lhese connections creates a risk oi Ilooding <br /> and I accept lhat risk. <br /> Signat�re h Y��-'- �� Date I Z 3 / �-o I `/ <br />