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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> / o �� r��' �' <br /> PropertyOwnE�Name(_�/. i <br /> InslallationAddres: IO l . �C" e t( /C✓ � " � <br /> /� /�y G' <br /> City:�[� r�T� State: V/1 Zip: �� <br /> ,' <br /> tvlaiiing Address(Ndi(IereutJ: __ <br /> City: . State: _ Zip: <br /> Emaii: Phone: ! ) <br /> Total Cost to Install Device ((rom contraclorinvoice): $�}�j� � O�x <br /> � <br /> Please verify the foliowing: <br /> (��m ihe owner of the property where'he backwater preveniion device�vas installed. � <br /> [�I worked wilh the contrador to determine the location for the backwater prevenlion device and ! <br /> understand thal the decision regarding the localion ot the device was mine. <br /> ��My contractor instructed me how to access, inspect, and maintain the devica. <br /> �- I understand that I am responsible for maintaining the backwater preveNion device and keeping <br /> it in good working order, unless it is installed in the city right•o(-way. <br /> �I sell my propeAy, I will make potential buyers aware of ihe backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> �m enclosing all,of lhe necc�sary papenvr�rk(use the yellow Rebate Submitlal Checklist). <br /> Select from the following: <br /> [�e coniraclor identified downspc�uls or other drainage Ilines Ihal were connected ro my sewer <br /> line (behveen my house and the installed device)and removed, or rerouled them. <br /> ❑ To my knowledge, my propert�� has no downspouls or other drainage cnnnecled lo my sewer line <br /> (behve=n my house and ihe in:talled device). <br /> ❑ There are downspouts or other drainage lines connncted to my sewer line (behveen my house <br /> and lhe installed device). I understand thal leaving these conneclions creates a risk of Flooding <br /> and I accept that risk. <br /> ; = ���// , <br /> Signature ' � Date � <br /> i <br />