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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: _ M(�fr(;� M nQ�'(� <br /> InstallationAddress: ��i,�l (��{�� ��)� <br /> City: �)'P�PTf State��_Zip; �b�� <br /> Maiiing Address (if dif/erentJ: <br /> City: State: Zip: <br /> Email: �,�'YI�1��� IA)hl dh��/ � Ilt'.'� Phone: ��).� 50 � 7 �i`7� <br /> Total Cost to Inslall Device(from contractor invoice): $ 2��-/q • �� <br /> Please verify the fo!iowing: <br /> �' I am the owner of the property where the backwater prevention device was installed. <br /> � I worked with Ihe contractor to determine ihe �ocation tor lhe bar.kwater prevention device and <br /> understand that the decision regarding ihe location of the device was mine. <br /> � My contractor instructed me how to access, inspect, and maintain the device. <br /> ,� � understand that I am responsible tor maintaining ihe backwater prevention devi�e and keeping <br /> it ir good working order, unless it is inslalled in the ciry right•oi-way. <br /> �' If I sell my property, I tvill make potenlial buyers aware of the backwater prevention device and <br /> the need to Inspact and maintain it on a regular basis. <br /> � I am enclosing all of ihe necessary papenvork(use the yeilow Rebate Submitlal Checklist). <br /> Select from the following: . <br /> ❑ The conlraclor identified downspouts or other drainage Ilines that were connected to my sewer <br /> line(between my house and tho installed device) and rernoved, or rerouted ihem. <br /> �To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and Ihe inslalled device). <br /> ❑ There arc downspouls or other drainage lines connected to my sewer Iine (between my house <br /> and Ihe installed device). I understand that leaving ihese conneclions creates a risk of flooding <br /> and I accept that risk. <br /> Siqnature r �" /�'`—���r�'U .� `� <br /> Datc � � J � <br />