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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation Address G-� l K(.� <br />Cily: �✓Q �e� Stale: � <br />Mailing Address (if diHerent): <br />City: <br />Email: <br />Slate: <br />✓ <br />Zip: � 0 2O I <br />Zip: <br />Phone: ( <br />Tolal Cost lo Install Device (from confrectorinvoice): $ c�"6U �.Og <br />0 <br />Please verify the following: <br />��i'am lhe owner of the property where lhe backwater prevention device was installed. <br />�i'�vorked with the contractor lo determine the location ior the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />�}'�41y contractor instructed me how to access, inspect, and maintain the device. <br />understand that I am respo isible for maintaining the back�vater prevention device and keeping <br />it in good working order, unless it is installed in the city right•ot-way. <br />�li I sell my property. I will make potential buyers aware ot ihe backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�—f am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the (ollowing: <br />��The contractor identilied downspo,its or other drainage Ilines lhat were connecled lo my sewer <br />line (between my house and the inslalled device) and rem� �ed, or rerouted lhem. <br />❑ To my knowledge, my propeAy has no downspouts or olher drainage connected to my sewer line <br />(belween my house and the installed devicc). <br />❑ There zre downspouts or olher drainage lines connected to my sewer line (between my house <br />and the installed device). I understand ihal leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature <br />, (3�✓� Date � 2� L5 , <br />