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�„ <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property0wnerName: ��.��' 1Vl!%C�le,(Ul J[�,. <br />InstallatfonAddress: y��O 2J1`%l.'�`.__aY� � <br />City: Fl/ �L�"Z'T stale: w�- _ Zlp:�� ZO f <br />MailingAddress(lfdiNerent): %�� ll/(�f �j l sT ST/2E£Z <br />�— <br />ciry: �'vC��lr._� s��a:�Q/� z�P: 94�(p� <br />Email: �YhL�C� {� (Yl ! � �OT'AigJ �- Phnne: (ZG� Z3'r' • �.�%� <br />CeW� <br />Tolal Cost lo Inslall Device (from contracforinvolce): 3 <br />Please verify the following: <br />� I am the o�vner of the properly where lhe backwater prevention devlce was inslalled. <br />�j I v�orked with the contractor to determine the locallon tor the backwater prevention device and <br />understand that the decision regarding lhe location of fhe devlce �vas mine. <br />� My contractor inslruded me how to access, inspect, and malntain tt;s devlce. <br />� I understand that I am responsible for maintaining the backwater prevenlion devlce and keeping <br />il in good working order, unless il Is Installed In the Gly right-of-way. <br />� II I sell my property, I will make potential buyers a�vare of the back�vater prevenfion device and <br />the need to inspeG and mainhain it on a reyular has!s. <br />� 1 am enctosi�� all of the nocossary paporwork (use the yellow Rebate Submitlal Checklist). <br />Select irom the following: <br />❑ The contractor ldenUfied downspouts or olher dralnage Ilines Ihat ware connected to my s��wer <br />line (6etween my house and the inslalled device) and removed, or rerouled them. <br />�.[i J To my knovaledge, my property has no downspouts or other drainage comiocted to my sewer line <br />(between my house and Ihe installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (beMleen my house <br />znd Ihe installed device). I understand ihat leaviny Ihese wnneclions croates a risk oT flooding <br />end I accept lhat risk. <br />Signat ' DaM � � 25 � 5 <br />