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Backwater Prevention �evice Rebate Program <br /> Q, Rebate App:,cation For�� i <br /> Property Owner Nam2: 1,� �G�/ /YJ�./l'J�7�� <br /> Installation Address: �i3 %�a�1LG�e//r/ /�c�i <br /> City: L v eoe�.�— _State� w!)' _Zip:�f7p� <br /> Mailing Address (il diKerant): (� 3 y `� ��� }�ti P l �V � <br /> City: �JJc�\` State: �'J � Zip: �t �� � `� <br /> Email: j"'1� � �i ��ocwcy,Mc�; l . �oi�t Phone: (9ty� 830 6G '{ P <br /> Total Cost to Inslall Device ((rom c.rontractorr•�voice): $ �.�.�. . � � <br /> Please verify the following: <br /> � I am the owner o(the property v�here the back�vater prevenlion device was installed. <br /> � I v�orked with the contractor to determine the location for the backv�ater prevention device and <br /> understand that the decision regarding the location o(lhe device�vas mine. <br /> � My contractor'nstructed me how to access, inspect, and maintain the device. 1 <br /> � I undeistand lhat I am responsible for maintaining the back�vater prevention device and keeping ( <br /> it in good wurking order, unless it is installed in ihe city right-of-way. ! <br /> (� If I sell my property, I will n:ake potential buyers aware of the bsckwater pre�•ention device and I <br /> � the need to inspect and maintain it on a regular basis. <br /> � I am enclosing all of the necessary papenvork(use the yellow Rebate Submiltal Checklist). <br /> Select irom the following: <br /> ❑ The contractor iclenlilied downspouts or other drainage Ilines that were connected to my setve; ! <br /> line (behveen my house and the installed device) and removed, or rerouted ihem. <br /> ❑ To my knowledge, my property has no downspouls or other drainage connecied to my sewer line � <br /> (behveen my house and the installed device). <br /> �There are downspouts or olher drainage lines connecled lo my se�ver line(behveen my house <br /> and lhe installed device). I understand thal leaving ihese connections creates a risk of iloodinc� <br /> and I �.ccept that risk. <br /> � <br /> Signature ,I�h' ���n.B'� Dafe �a' .3 �� <br /> i <br /> l <br />