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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> PropertyOwnerName: hc.��J T^r�\�( _ <br /> Installation Address: ,.Zy�I P�rc' S"1� <br /> Ciry:�v�---� Slate:l r�7� Zip: I'Y��'f <br /> Mailing Address (il di(lerentJ: S/�U �/,•zl„� �r• i�' � <br /> City: tLtr�}� State: .I-� Zip: ��'2��J <br /> EmaiC Phone: �'f ) ,�� CGb' C�'�' <br /> Total Cost to Install Device (lrom contracfor invoice): 5 2 ,Scc � <br /> Please verify thc following: <br /> �� I am the o�vner of the property where the backwater prevention device was installed. <br /> � I worked wilh the contractor to determine the location for the backwater prevention device and <br /> undersland that the decision regarding the location of the device was mine. <br /> ��Ay contractor instrucled me how to access, inspecl, and maintain the device. <br /> � I understand lhat I am responsible for maintaining the backwaler prevention device and keeping <br /> it in good �vorking order, unless it is installed in the cily right-of-way. <br /> If I seii my property, I�vill make potentiat buyers aware o(the backv�ater prevention devi:e and <br /> �he need to inspect and maintain it on a regular basis. <br /> I am enclosing all of the necessary papenvork (usc the yellow Rebate Submittal Checklisl). <br /> Select from the following: <br /> ❑ The wntraclor idenlified downspouls or olher drainage Ilines that were connect�d to my sewer <br /> tine (belween my house and lhe inslalled device)and removed, or rerouted lhem <br /> \(�'j] To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and Ihe installed device). <br /> ❑ There are downspoufs or other drainage lines connected to my sewer line (between my house <br /> and the installed device)..I understand Ihat leaving these conneclions creates a risk of flooding <br /> and I accept lhal risk. <br /> Signature ��^✓��� Date 7 �!- I � <br />