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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: Vl/! l. � l/�M R. L yO�V <br />Installation Address ,��Q I I �R�N/�P� �v� � <br />c�ry: r_'U�RF TT state: GvA , ziP: 982d 1 <br />Mailing Address (ildrflerenf): <br />City: <br />State: <br />Lir,. <br />Emai�:_ �PA . 4 yoN�q i RvN7l t�F , C UN1 ___ . Fhone. {�Lj'� �T-7d - L SN 3_ <br />� C�1� <br />Total Cost to hstall Device (from contractorinvoice): 5,;`'J� <br />Please verify thc following: <br />� I am the owner oi the property where the backwater preven;ion device �vas installed. <br />� I worked with the coMractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the focation of the device was mine. <br />f� My conlraclor instructed me how to access, inspect, and maintain the device. <br />(�j I understand thal I am responsible for maintaining the backwaler prevention device and keeping <br />it in good working order, unless it is installed in the city right•of-way. <br />p If I sell my property, I will make potential buyers aware of the backwaler prevention device and <br />the need to inspect and maintain it on a regular basis. <br />❑ I am enclosing all of lhe necessary paperv+ork (use the yello�v Rebate Submittal Checklist). <br />Select irom the (ollowin0: <br />� The contractor identified downspouts or other drainage Ilines thal were connected to my sewer <br />line (betwee� my Yiouse and lhe installed devicc) and rernoved, or rerouted them. <br />� To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(beM�een my house and Ihe installed device). <br />❑ There are downspouts or other drainage lines connecled to my sewer line (between my house <br />and the inslalled device) I understand that leaving Ihese connections creates a risk of flooding <br />and 1 accept that risk. <br />Signafurc_ 1��� i, / Date � �� Z�,`T /� <br />