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i <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner tvame: I�D 6�/t� �-- Gf'/�/Uy�' GO���� � � <br /> InstallationAddress: I�7y� ��hE ����� �ruG <br /> City: �YJ�%% State: �'1'�f� _zip: 9�w� - <br /> Mailing Address (if di(ferent). <br /> City: _ __ State: Zip' <br /> Email: Phone: ( )_ <br /> II Total Cost lo Install Device (/rom conlracfor invoice): S --,�=�p—(_l� <br /> Please verify the tollowing: <br /> � I am the owner ot the property where ihe backwater prevention device v�as inslalled. <br /> � I �vorked wiQi the contraclor to delermine the localion for the backwater prevention device and <br /> understand thal the decision regarding the location of the device�vas mine. <br /> f� My conirac;or instructed me ho�v to access, inspect, and maintain the device. <br /> � I understand thal ! am responsible for maintaining the backwater prevention device and keeping <br /> it in good�vorking order, unless il is installed in the city right-of•way. <br /> �; It I sell my property, I�vill make polential buyers aware of the hack�:�ater prevention device and <br /> the need lo inspect and maintain it on a regular basis. <br /> ;�j I am enclosing all of lhe necessary papenvork (use lhe yellow Rebate Submiltal Checklist). <br /> Select from the following: <br /> (_] The contractor idenli(ied do�vnspouls or other drainage Ilines that were connecle.d lo my sewer <br /> line (belween my house and the installed devicc)and removed, or rerouted lhem. <br /> [E�j To my knowledge, my propeAy has no downspouts or olher drainage connected lo my sewer line <br /> (beteveen my house and the installed device). <br /> [_J There are downspouts or other drainaye lines connected lo my sewer line (behveen my house <br /> and the inslalled device). I understand that leavinq Ihese connections crea�es a risk of flooding <br /> and I accepl that risk. <br /> Signature <br /> �%�'�' l!" "� "V. �Gfl1^^'i/` W Date 2"�" ��l y^ <br />