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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Nam <br />Installation Address: <br />City: ttye'1/a State: lJc�- Zip:2.9 1 <br />Mailing Address (if different): <br />City: <br />State: <br />Zip:__ <br />Email: C,wr. o + r TI*4� Phone:(;;;) «t1—�TfG <br />Total Cost to Install Device (from contractor invoice): 5 <br />Please verify the following: <br />f7 I am the owner of the property where the backwater prevention device was installed. <br />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 />1 I 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 />f�1 If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />`j the need to inspect and maintain it on a regular basis. <br />[7J 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 />rTo my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house nd the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the ink�s ,a,iled device). I understand that leaving these connections creates a risk of flooding <br />and I,accept that risk, <br />Date _ <br />