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Backwater Prevention Device Rebate Program <br /> . Rebate Application Form <br /> Property Owner Name:��� � e �v� /–/ e�__� <br /> Installa:ion Address: /$ 3 / �q��� �U� • <br /> City: �,Ilr✓G_�_—__State� �✓�_ZiP_�p z0 � <br /> �vlailing Address (i(diHerent): G��� Z�o r�' � �'G N�% <br /> Ciry'�"+C.N."'Ft �Q�rS State: _�✓� Zip:��L�Z _ <br /> Email: �v,rf���'�� �` jO +�,'I, eb�'+Phone� {ylll Y/S ZZY`� <br /> I . $b' <br /> Total Cost to Install Device (Irom contractor invoice): 5��� <br /> 1 <br /> Please verify the following: <br /> I� I am the owner of the property where the backwater prevenlion device was inslalled. <br /> � I�vork2d with the contractor to delermine the location for the backwater prevenlion device and <br /> ur,derstand that Ihe decision regarding ihe location ot ihe device v+as mine. <br /> � My contraclor instructed me how to access, inspect, and mainlain the device. <br /> � I understand thal I am responsible for maintaining the backwaler preventirn device and keeping <br /> it in good working order, uniess it is installed in the cily right-oi-way. <br /> � If I sell my property, I will make potential buyers aware oi the back�vater prevention device and <br /> lhe need to inspecl and maintain il on a regular basis. <br /> �J I am enclosing all ot the necessary paperwork (use the yellow Re6ate Submiltal Checklist). <br /> Select irom the following: • <br /> ❑ The conUactor identified downspouts or other drainage Ilines lhat were connected to my sewer <br /> line(belween my house and the installed device)and removed, or rerouted them. <br /> [vj�To my knowledge, my propeAy has no downspouts or other drainage connecled to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouls or olher drainage lines connected to my sewer line(belween my house <br /> and the installed device). I undersland that leaving these connections creates a risk ot Oooding <br /> and I accepl thal risk. <br /> Signature <br /> , Date � Zg �s <br /> � <br />