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44Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: ✓) <br />Installation Address: 35 U -7 nen k S /iti-L <br />City: r C-�21 <br />Mailing Address (if different). <br />City: <br />Email: <br />Stale: �✓/� _ Zip: I' U t <br />Slate: <br />Total Cost to Install Device (from contractorinvoice): $ <br />Please verify the following: <br />Phone:( <br />I am the owner of the property where the backwater prevention device was installed <br />m 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 />[�( My contractor instructed me how to access, inspect, and maintain the device. <br />® I understand that I am responsible for maintaining the backwater prevention i evice and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />® If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />Qj I am enclosing 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 />To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />[J 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 risk. <br />Signature— �� Date -z —/Z- �� <br />