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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />InstallationAddress:.2U/� K�JI(�� � �UG <br />City: ,��t���% State: w� Zip: Ci p.,� v � <br />Mailing Address (il dilferenq: <br />City: State: Zip: <br />Email: Phone:�'�j) � �-�� � <br />oa <br />Total Cosl to Install Device (from contractor invoice): � 2�C%L� �� <br />Please verify the following: <br />�am the o�vner of the property where the backwater prevention device was instalied. <br />Ql I worked wilh the contractor to determine the location for the bacY.water prevention device and <br />� understand thal the decision regarding lhe location of ihe device was mine. <br />�My contraclor instructed me how to access, inspect, and maintain the device. <br />�I understand thal I am responsible for maintaining the backwater prevention device and keeping <br />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 awar= of the backwater preven!ion device and <br />Ihe need lo inspect and maintain it on a regular basis. <br />�}-I am enclosing all o( the ner.essary papenvork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The conlraclor idenlified downspouts or other drainage Ilines that �vere connected to my sewer <br />line (bebn�een my house and the installed device) and removed, or rerouted ihem. <br />�To my knowledge, my property has no downspouts or other drainage connecled to my sewer line <br />(between my house and the inslalled device). <br />❑ There are downspouls or olher drainage lines connecled to my sewer line (betvueen my house <br />and the installed device). I understand that leaving these connections creales a risk of flooding <br />and I accepl lhat risk. <br />Signature �{ �•' � Date �� � <br />