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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Nam�lJ�i yY���;{��r ��e )� /7 �'�-� <br /> Inslallation Address: � J C7 S �J C 1 C �� e `Lf�Y � � C. _. ___ <br /> c��y:� () Q v e t'� scat�: �� z�P: � � a (� 1 <br /> Mailing Address(iI dillerent): SG YYl C <br /> City:_ Slate: Zip: <br /> Email:��uW C Y,C�. 1 Y r � 56 (c� CQ-�rA i ��hone:�� 7 � .3 -O� O y <br /> �— <br /> Total Cost to Inslall Device (trom contracforinvoice): $ "al• g g <br /> Please verify the following: <br /> � I am lhe owner of the properly where lhe backwater prevention device was installed. <br /> � I worked with the conlraclor to delermine the loc:tion for the backwaler prevention device and <br /> understand tn�t the decision regardiny the location of lhe devic?was mine. <br /> "�f.My contractor instructed me how lo access, inspect, and maintain the device. <br /> -� I understand thal I am responsible for maintaining the hackwaler prevention device and kceping <br /> it in good working order, uNess it is installed in lhe cily right-of-way. <br /> �( If I sell my property, I will make potential 6uyers aware of the backwaler prevention device and <br /> the need to inspecl ar.d mainlain it on a regular basis. <br /> �� 1 am enclosiny all ol the necessary papenvork(use the yellow Rebate SubmiUal Checklist). <br /> Select from the following: <br /> ��[ 'ihe conlraclor identi(ied downspouts or olher drainaye Ilines Uial were connected lo my sewer <br /> line (betvoeen my house and the installed device} and removed, or rerouted them. <br /> I � To my kiiowledn�, my property has no downspouls or other drainage connected to my sevaer line <br /> (between my house and lhe inslalled device). <br /> U There are downspouts or other drainage lines connected la my sewer line (between my house <br /> and the installed device). I understand lhal leaving these conner.tions creates a risk of(loodin� <br /> and I accept that risk. <br /> ��7 ---�-�- � Ilv �/� <br /> Signafure . ±�n�Ao, �(���rZD/� � _ Date ___ <br /> c <br />