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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation Address, /1. -)e - <br />City: � s 1' State. _ 1 (� [� Zip: �� �c1GL <br />r: I <br />Mailing Address (if different): n <br />City: I){i/�Q {` State: " rl—Zip:— <br />Email: Phone:�� <br />Total Cost to Install Device (from contractor invoice): S <br />Please verify the following: <br />WT 12m the owner of the property where the backwater prevention device was installed. <br />j;" I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />g My contractor instructed me how to access, inspect, and maintain the device. <br />P: A understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed In the city right-of-way. <br />Q' It I sell my property, I will make potential buyers aware of the backwater prevention device and <br />I the need to inspect and maintain it on a regular basis. <br />;) I am enclosirg all of the necessary paperwork (use the yellow Rebate Submittal Checklist) <br />Select from the following: <br />[] The contractor identified downspouts or other drainage (lines that were connected to my sewer <br />line (between my house and the installed device) and removed. or rerouted them. <br />[• n' o my knowledge, my properly has no downspouts or other drainage connected to my sewer line <br />II (between my house and the installed device). <br />There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that nsk. <br />lj� <br />signature %' Date <br />