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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property O�vner Namc: f����y��,�[�C/� _ <br /> Inslallation Address: _ 33�/NG— ST <br /> c�iy: ����7 State: uJ/�I - Zip:��Lo/ <br /> �, Mailing Address(i(di(ferent):_ _ <br /> City� State: Zip <br /> � <br /> � Email: Phone� ( ) <br /> � Total Cost to Install Device (from confractor invoice) S �i��f _ <br /> I <br /> Please verify the following: <br /> �am the o�vner of the property where the back�vater prevention device�•:as installed. <br /> � I worked with the contractor to determine the location (or the backwaler prevention device ard <br /> understand that lhe decision regarding the localion of the device was mine. <br /> '�� MS'contractor instrucled me ho�v to access, inspecl, and maintain the device. <br /> � I understand that I am responsi6le for maintaining Ihe backwaler prevenlion device and keeping <br /> it in good working order, uNess it is installed in the ciry right-of-way. <br /> [�; If I sell my property, I will make potential buyers a:vare o(the backwaler prevention device and <br /> Bio need to inspecl and mainlain it on a regular basis. <br /> � I am enclosing all of the necessary papen•rork (use ihe yellow Rebale Submittal Checkl�st) <br /> Select from tf�e following: <br /> j� The contracbr identified dor;nspouts or olher drainage Ilines that wcre cnnnected to my see:er <br /> linc(between my house and,the inslalled device)and removed, or rerouled them. <br /> (�To my knov�ledge, my property has no downspouls or o�her dr�inage connected to my se�ver line <br /> (behveen my house and the installed device). <br /> Lj There are downspouts or other draina9e lines connected lo my sewer hne (beN+een my house <br /> and the installed device). I understand that leaving these connections creates a risk ol flooding <br /> and I accept that risk. <br /> Slgnature�E�n�,�K� _ Date .3—Z3—If <br />