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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property O�vner Name� ✓�i�-- �V ��*' �'�% <br />InstallationAddress: ��"✓ ���0.�dma � ��`� <br />City: �� State: W� Zip: '7 V/ V 1 <br />Mailing Address (if dilferent): <br />���y; State: Zip: <br />Email:dQblQiYY►l.(J(C_L1L�J_���_%.+� Phone: � �'�D <br />c� <br />Total Cost to Instail Device (7rom contractorinvoice): $ ����"� <br />Please verify lhe following: <br />� am the owner of the property wl�ere the backwaler prevention device was installed. <br />� I v�orked with the contractor to determine the location For the backwater prevention device and <br />understand that the decision regarding the location of the devir.e was mine. <br />❑ My contraclor instructed me how to a�cess, inspecl, and maintain the device. <br />� I understand that I am responsible for maintaining ihe backwater prevention device and keeping <br />it in good wnrking ordc�r, unless it is installed in lhe cily righl-of-way. <br />� If I sell my property, I wiil make potenliai buyers aware of thc backwaler preveNion device and <br />ihe need lo inspecl and maintain il on a regular basis. <br />� I am enclosing all of the necessary paperwork (use lhe yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The conlraotor idenlified downspouts or other drainage Ilines that were connected to my sewer <br />line (behveen 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 />(�eN+een rny house and the inslalled device). <br />❑ There are downspouts or other Arainage lines connected to my se�ver line (between my house <br />and the installed device). I understand that leaving lhese conneclions creates a risk of floodmg <br />and I accept thal risk. <br />Si naturel��`���1 �"�1���� `" -" Dafe � 2`� �� <br />� <br />