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Backwater Prevention Device Rebate Program <br /> Rebate Appiication Form <br /> Property Owner Name: �T,l� An�� L �D� <br /> Installation Address ��v��9l.�����?� LLP . _ <br /> City: � � __ State:__��_Zip:����__ _ <br /> Mailing Address (if dif(erenf): <br /> City�_ State: Zip: <br /> � Email: /I UaZ•� _Phone:('y�s_Z.�Z —� /2- <br /> Total Coat to Install Device (from conUactorinvoice): S�aJ� � �� <br /> ; Pleas verify the foliowing: <br /> I� ��m the owner ot the property v�here the backwater prevention device v�as ins.�Iled. <br /> I worked with the contraclor lo determine the localion for the backwater prevention device and I <br /> �nderstand that lhe decision regarding the location of the device aras:nine. ! <br /> I <br /> ' d y�contractor instrucled mc ho:v to access. inspect, dnd mainlain the device. <br /> � I understand that I am responsible for maintaining ihe backwaler prevention device ancl keeping <br /> rS good working order, unless it is inslalled in ihe city rignt-of-way. <br /> i I(I sell my property, I will make potential buyers aware of ihe backwaler prevention devicc and <br /> � the need to inspect and maintain it on a regular basis. <br /> I I am enclosing all of lhe necessriry paperwork(use the yellow Rebata Submiltal Checklist). <br /> Select(rom the fol�owing: ( <br /> i <br /> � <br /> The contractor idenlified downspouls or other drainagc Ilines lhal were connected to my se�ver <br /> line (behveen my house and the installed device)a�d removed, or rerouted Ihem. <br /> ❑ To my knowiedge, my property has no downspouts or other drainage connected lo my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the installed device). I understand that leaving these connections creates a risk of Booding <br /> and 1 accept that risk. <br /> � Signature ��Date !�_�T <br /> i <br />