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Backwater Prevention Device �Rebate Program <br /> Rebate Application Form <br /> ' f ` �Pro�erty Owner Name: � � - �J 69J u <br /> . ' <br /> Inslallation Address: � � � �LtL <br /> City: � _ ? � . _State:��Zip: ��,� t <br /> Mailing Address (i(dilferenf):_ <br /> City: Slate: Zip: <br /> Email: _Pho�ie: ( ) <br /> Totai Cosl to Install Device (lrom confractor invoice): $ <br /> Please verify the tollowiny. <br /> [� I am ihe owner o(the propely where the backwater prevention device was installed. <br /> � I worked viilh lhe :ontra�lor to determine the location for the backwater prevention device and <br /> understand Ihal the decision regarding lhe location of the device was mine. <br /> � My contractor instructed me how to access, inspecl, and maintain the device. <br /> [� I u�derstand that 1 am responsible(or maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in thc city right-of-way. <br /> �] If I sell my property, I will make potentiai buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> [�J I am enclosing all of llie necessary paperwork (use the yellow Rebate Submillal Checklist). <br /> Select from the followinc�: <br /> ❑ The conlraclor identitied downspouts or uther drainage Ilines that were connected to my sewer <br /> line(between my house and the inslalled device)and ranoved, or rerouled them. <br /> I YI To my knowledge, my property has no downspouls or other drainage connected to my sewer line <br /> �� (between my house and the installed device). <br /> ❑ There are downspouts or olher drainage lin��5 conner;ed to my sewer line (behveen my house <br /> and Ihe instalied device). I understand th;,t leaving lhese conneclions creates a risk of floodiny <br /> and 1 accepl thal risk. <br /> � <br /> Signature Date � ✓ <br /> � <br /> � <br /> . _ . -- -- - - - - . - ----•-- - --- ----------- - _ -- --- ----•-I <br />