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i <br /> Backv�ater Prevention Device Rebate Program <br /> Rebate Application Form � <br /> i <br /> _. � . . : <br /> Propeny Owner Name: � � �. n ' ' <br /> Installefion Address:����'f(;��.(a-!` 1 I P �� N'I�1; � <br /> cay:� �' s�: (�,'�}- _ap:� S��G I ; <br /> � <br /> Maiting Address(Ndlflerent}: i <br /> City: Sfate: T�p: , <br /> Email: ���lilp,� �T,��,_([i11�Phone: (�,���-.��'��i •--�'�— � <br /> Total Cost to Install Device(from conhactor invaiceJ:$ I � U' S � J • <br /> Please verify the following� <br /> 0 I am the owner of the propeRy where the backwater prevenUon device was installed. ; <br /> � I worked wMh ihe coMractor to determine the locatlon tor the backvrater preven6on device and <br /> understand thet the decfsion regardfng the locatlon of ihe dev(ce was mine. <br /> � My c�ntrador instructed me how to ac�ess, Insped,and maintain the device. <br /> � I understand that I am responsible for maintainfng the beckwater prevention device and keeping I <br /> it in good working order, unless R is installed in the city righty�f-way. , <br /> [✓r If I sell my p�opeAy,I will make potential buyers aware of the beckwater preventlon devfce and <br /> ihe need to inspect end meintain H on a regular basls. j <br /> [� I am enGosing all of the necessary papervvork(use the yeltow Rebete Submittal Chedclist). � <br /> i <br /> Select from the following: <br /> i <br /> [�The contractor identfied downspouts ar other drainege Ilines that were connected lo my sewer <br /> line (betvreen my house and the inst�iled device)and removed,or rerouted them. i <br /> [� To my knowledge,my prnF..rty has no dovmspouts or other drainage connected to my sewer lino <br /> (between my house and the Installed device). <br /> i <br /> ❑ There are downspouLs or other drafnage Iines connected to my sewer line(between my house <br /> and the instailed device). i understand that leaving these connedions aeeles a risk of floodfng <br /> and I accept that risk. i <br /> ' . �� ! <br /> Slgna(ure �� 1 � Date i <br /> � <br /> :- <br /> .. � <br />