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Backwater Prevention Device Rebate Program <br /> Q, ,E„ Rebate Application Form <br /> Property G:+ner Name: '%✓V��J`�W �-Y'��' 1✓" <br /> Installation Address �� ' `� C �� C��GGE� ��� <br /> �,iy: E ►�£2 E77 State: l��H z�p: �1 �ZO ] I <br /> Mailing P.ddress(if:i�.Yerent): � <br /> City: ----- State: Zip: I <br /> Email: lryCJi'�BWI"�I `� _ G�,/, ��h�tmail, GO��phone: (�6) 7G3—gz�7 <br /> Total Cosl to Install Device. ((om contracfor invoice): 5 �2499 59 <br /> Please verify the following: <br /> � I am the owner oF the property where the bac4cwater prevention device was installed. <br /> [J I worked with the contractor to delermine the localion for the backwater preventien device and <br /> understand that the decision regarding the location o(the device v✓as mine. <br /> [xj My contractor instructed me how to access, inspect, and maintain the device. <br /> � I understand that I am responsible tor maintaining ttie backwater prevention device and keeping <br /> it in good tvo�king order, unless it is installed in the cily righi•oF-way. <br /> [� If I sell my proparty, I eJill make potential buyers aware of the bacfavater pravention device and <br /> th=need to inspecl anJ maintain it on a regular basis. <br /> [�; I am enclosing all of the neccssary paper.Jork(use the yellow Rebate Submittal Checklist). <br /> Sclect from tlie following: <br /> ❑ ihe conlractor identified downspouls or olher drainage Ilines tliat were cnnnected io my sewer <br /> line(behti�een my house and the inslalled device) and removed, or rerouted them. <br /> 0 To my knowledge, my property has no do��mspouts or other dreinage connected lo my sewer line <br /> (behveen my house and lhe installed de�:�ce). <br /> ❑ There are downspouls or other drainaga lines connecled to my sewer line(between my house <br /> and lhe installed device). I undersland that Ieaving these conneclions creates a risk of(looding <br /> and I acc�N:that risk. <br /> Signature i��"v�wl /� �^�Date 7� �S <br />