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., . <br />., <br />�, . <br />ackwater Prevention Device Rebate Program <br />Rebate Application Form <br />Preperiy Ovmer Na � <br />Inslellation Atldress: _�_ <br />City: L.{�c P� �1"� <br />Mailing Address (if di)(erenf): _ <br />City: <br />State: <br />l�Ll� zp:��ao 1 <br />F.mail: Phone: ( ) _ <br />Total Cost to Instali Dev�ce (lrom crontracfQr �nvoice). S�_0 � nv <br />Pleae vority the tollowing: <br />1 am tfie owner of the property where the backwater prevention de�4ce was fnslalled. <br />�worked with the conlraCtor to determine the location for the bdckwater preventlon devlce and <br />undersland Ilial the decislon regarding Ihe locatior of the devlce was mine. <br />[r� My contrector instructed me how lo access, in�pect, end maintain the device. <br />�understand that I am responsible for mafntaining the backvrater prevention devlce and keepin9 <br />, It in pood working order, unless d is Installed m the city nghtot-way , <br />� I sell my propeny, I�+nll make potenbal buyers aware Ot the backwater prevendon de�ice and <br />th need to insped and maintain it on a repular t�asis <br />I am enclosing all of the necaccary paperwork (use lhe yellow Rebnte 8ubmlqol Checklist). <br />scioct irom the foilowing: • <br />� The contrector identifiod downspouts or other drainage Ilinos Ihat were connected to my sawer <br />Ilne (between my house �nd the installed device) and rerooveci, or rerouted Ihem, <br />[�To my knowiedge, my proporty has no downspouts or olher dtainage cohneUed to my sewer line <br />(between my houso and tlw �nstelled device)., . <br />�] lliere are dvwnspouls or olher drainage Ilnea connected lo my aewer line (hetween my house <br />. and the instatied device), I undersland that leaving ihese conneclions creafes a risk of flooding <br />and I accept that risk <br />. • �i <br />i• � <br />i:_, .__.�. <br />_�r,»(/ _ � � �--.. <br />�= <br />� <br />i <br />i <br />