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_ _ - - - - - - . - - - ._ - _ _- _ - -- _ i <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> PropertyO�merName: �-hY'iSSe� �ehdli _ <br /> Inslallation Address: ��.2`.� PI �1(: S f VC�� <br /> c��v: F v e����Ft _s�ace: W �? z�p: �8�2 o r <br /> � Nlaiiing Address (il dilferent): <br /> ICity: State: Zip: <br /> i <br /> Email� Phone: (y�sj $�4'�'}0/ <br /> Total Cosl to Install Device(lrom contractor invoice): 5 <br /> Please verify the following: <br /> �i I am the o�•mer of the property�vhere the backvrater prevention device :vas installed. <br /> ❑ I worked�v�th the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the Iocation of the device�vas mine. <br /> ❑ My contraclor instructed me hovr to access, inspecl, and maintain the device. <br /> [x I undersland lhai I am responsible (or maintaining the back�vater prevention device and keepin3 <br /> it in good working order, uNess it is installed i�the city righl-of-v_�ay. <br /> [�if I 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 �asis. <br /> ❑ I am enclosing all oi the necessary papenvork(use the yellow Rebate Submittal Checklist). <br /> Select trom the following: <br /> ❑ The contrector identi(ied downspouts or other drainage Ilines lhat were connecled to my sewer <br /> line (between my house and the installed device)and remove�, or rerouted them. <br /> ❑ To my knov�ledge, my properry has no downspouts or other drainage connected to my sewer line <br /> (behveen my house and the installed device). <br /> [71 There are downspouts or other drainage lines connected to my sewer line (between my house <br /> and Ihe inslalled device). I understand that teaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Signature L�.wvv�Opn�t� � Date S '�3 - 2 oiS� <br />