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'A✓, <br />� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />ProperlyOwnerName: ��� �nc0 Lu� I In � nn�l <br />Installation Address: ��� � �J �C�f1P.��� . <br />City: �V�� �.— State: A/ l i Zip: 9f��� / <br />Mailing Address (il di(/ereni): <br />Ciry: <br />State: <br />Email: \ln7�iY1P��n�"ier,['_n►'vi Phone:(qg;).�5�'�13�� <br />' � • r— � , c� <br />Total Cost to Install Device (from contractor invoiceJ: $�j � _ <br />Please verify the following: <br />� I am the owner of the property where the backwater p�,..�ntion device was inslalled. <br />[]' I worked wilh 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 />0 My conlractor instrucled me how to access, inspect, and maintain lhe device. <br />[�] I understand thal I am responsible for mainlaining the backwater prevention device and keeping <br />it in good working order, unless il is installed in the cily right-oi-way. <br />[J� If I sell my property, 1 will make potential buyers aware of the backwater prevention device and <br />lhe need lo inspect and maintain it on a regular basis. <br />�I am enclosing all of lhe necessary papenvork (use the yellow Rebate Submittal Checklisl). <br />Select from the following: <br />❑ The contractor identitied downspouls or other drainage Ilines th�t were connected lo my sewer <br />line (between my house and the installed device) and removed, or rerouted lhem. <br />{✓]' To my knowledge, my property has no downspouts or olher drainage connecled to my sewer line <br />(between my house and the installed device). <br />❑ TherQ are downspouts or other drainage lines connected to my sewer line (belween my house <br />and Ihe inslalled devic��). I understand that leavin� these connections creates a risk of fiooding <br />and I :�ccept ihat risk. <br />Signaturc �l \ l Date � � � � � <br />