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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: = <br />Installation Address: ? <br />City: �J�e�( V <br />Mailing Address (if different): <br />City: <br />State: L-tD(V- Zip:_ ?F ZP ( <br />Slate: <br />Email: _t r. cQ,t ctlo�ol cui� e� e+n n I . c,�� Phone:��'�7�E' <br />Total Cost to Install Device (from contractor invoice): $ �_a��';a <br />Please verify fhe f Mowing: <br />(i am the owner of the property where the backwater prevention device was Installed. <br />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 />21iNly contractor instructed me hour to access, inspect, and maintain the device. <br />[Jil 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 />[)�If 1 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 />i <br />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 />(jiTo 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 />Signatur44�2 �-: Date J� -/y' �� <br />