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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property owner Name: CRez ` l5V - -- -- <br />Installation Address: I l z� D� 5 �AV O n — <br />City: a e71 State: A Zip: �I 3 � — <br />Mailing Address (if different): <br />City: <br />Email: <br />State: <br />Total Cost to Install Device (from contractor invoice): S <br />Please verify the following: <br />Phone: (jz53q4-L24z <br />a43l - Sa <br />ZI am the owner of the property where the backwater prevention device was installed. <br />01 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 />� ly contractor instructed me how to access, inspect, and maintain the device. <br />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 />ja <br />If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and r...,,rnain it on a regular basis. <br />/J 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 cnnnecled to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />u 1 o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(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 risk. <br />Signature In 11` - Date �D/ <br />