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Backwater Prevention Uevice Rebate Program <br />E,�, Rebate Application Form <br />Property Owner Name: / e�0 �w/►��� <br />Instailation Address: Ci�� � �• � � � <br />City: � State: � Zip: � ��l <br />Mailing Address (if diNerent): <br />Cily: � <br />-- Slate: <br />Email: � �J� ` <br />Total Cost to In all Device (lrom confractor <br />Please verify the follawing: <br />�� <br />(`) . � <br />Phone: <br />� I am lhe ovmer of the property where the backwater prevention device was installed. <br />�I worked v�ith ihe contractor to determine the location for the backwater prevention device and <br />understand thal the decision regarding the location of the device �vas mine. <br />� My contractor instructed me how to access, �nspect, and maintain the device. <br />�I understand that 1 am responsible for maintaining the backwater prevention device and keeping <br />il in good working order, unless it is installed in the city right•of-�vay. <br />�If I sell my property, I will make potential buyers aware o( lhe backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�/ � I am enclosing all of the necessary paperwork (use the yellow Rebale Submittal Checklist). <br />r� <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (behveen my house and the installed device) and removed, or rerouted them. <br />To my kno�vledge, my property has no downspouls or other drainage con� ecled to my sewer Iine <br />(behveen my house and the installed device). <br />�There are downspouts or other drainage lines connected to my sewer line (belween my house <br />and the installed device). 1 understand that leaving these connections creates a risk o( ilooding <br />and I accept that risk. <br />��r�� Date <br />