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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Proper�y Oemer Name: <br />Inslallation Address: _� � 3� �C� n � r t� �� <br />City. _� � f I _ State: _(�i/n Zip: � � � U � _ <br />Mailing �ddress (il di(ferenf): <br />City: <br />Email: <br />State: <br />Total Cost to Inslall Jevice (lrom confractor invoice): 5 <br />Phone: (y�s7 �..�(�=�7 �j 7i) <br />�• <br />Please verify the followinc�: <br />I am ihe owner of ihe property �vhere the backwater prevention device was �nstalled. <br />�worked wilh the contractor to determine lhe location for the backwater prnvention device and <br />understand thal the decision regarding the location of lhe device vras mine. <br />� <br />�, <br />h1y contractor instrucled me how to access, inspect, and maintain !he device. <br />I understand Ihat I am responsible for maintaining the backwaler prevention device and keeping <br />it in good vrorking order, unless it is ins,alled in the cily right-o(-Lvay. <br />Lf If I seli my property, I will make potential buyers aware of the backwater pre��ention device and <br />the need lo inspecl and ma�n(ain il on a regular basis. <br />� I am endosing all of the necessary papenvork (use Ihe yello�v Rebate Submillal Checklist) <br />Select irom the following: <br />� i'ihe contractor �denlified dovmspouls or other drainaye liines lhat �vere connected to my smver <br />line (belween rny house and !he installed device) and removetl, or rerouled them. <br />i� To my kno�vledge, my property has no do���nspouts or o�her drainage connected to my se�ver line <br />(behveen my house and lhe installed device). <br />❑ There are do�vnspouls or olher diainage lines commcted to my seti�er line (behveen my house <br />and the installed device). I understand that Ieaving Ihese conneclions creates a risk of floodinc7 <br />and I accent th;it risk. <br />Signaturc ���L�L ��� _ '�� Date � �_l ^ � _� <br />I — — <br />