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Backwafier Prevention Device Rebate Program <br />Rebate Application Form <br />PropeAy Owner Narr <br />Installation Address: <br />City: �kiG� State: �}�_ Zip: �%�2�� <br />Mailing Address (if diflerent): <br />City: <br />State: <br />Email: • 5 �C� � I L�hone: (� �J�' I ¢�� ! <br />1 '�/ Z O <br />Total Cost to Install Device (/rom contracror invoice): $��7 d" %� <br />Please veriy the following: <br />� I am lhe owner oi ihe property where the backwater prevention device was installed. <br />�J I worked with 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 />�j My contractor instructed me how to access, inspect, and maintain the device. <br />f�l I understand that I am responsible Ior maintaining the backwater prevention device and keeping <br />�C it in good working order, unless it is installed in the city right-of-way. <br />'�] If I sell my property, I will make potential buyers aware of the backwa[er prevention device and <br />�� the need to inspect and maintain it on a regular basis. <br />(�1 am enclosing all.of lhe necessary paperwork (use the yellow Rebate Submirial Checklist). <br />v� <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (beNveen my house and the instalied device) and removed, or rerouted them. <br />(YI To my knowledge, my properly has �o downspouls or other drainage connected to my sewer line <br />�C (belween my house and the installed device). <br />❑ There are downspouts or ather drainage lines connected to my sewer line (between my house <br />and ihe installed device). I understand that leaving lhese connections creates a risk of flooding <br />and I accept that risk. <br />Signature � I Oate � � <br />� <br />