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� Backwater Prevention Device Rebate Program <br /> a Rebate Application Form <br /> Property Owner Name: !�'�F'�LCo Lm •�1'I U St:-3 <br /> InstallationAddress: �`y�`r' ���cc��'�(,L� ,+,�-�-v <br /> City: �`�VCF(Lt-'r�r' _State: w��- - Zip: 9�20 / <br /> Mailing Address (if diNerent): 3`1-3 `Z ( t 5��u��'/s S�C' _ <br /> City �-1�'n�s�+ state� ���'- . Zip. F�2;'O <br /> Email: Phone: (2.[Q,. �'D— 83$ ( <br /> Total Cost to Install Device((rom conl2etorinvoice): 5 5�'�" Z� 1 �0 - � � <br /> Please verify the following: <br /> �am the ovmer of the p�operty where the back�vater prevention device e+as installed. <br /> j�l worked with the contractor to determine the location for the bacicwaler prevention device and <br /> understand that the decision regarding the location o(lhe device was mine. <br /> �My contractor inslructed me how ro access, inspect, and maintain lhe device. <br /> �" I undersland that I am responsible for mainlaining the backwater prevention device and keeping <br /> it in good�vorking order, unless it is installed in the city right-of-way. <br /> �If I sall my property, I will make potenlial buyers aware o(the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> ,� I am enclosing all of the necessaiy papenvork(�se lhe yellow Rebate Submittal Checklist). I <br /> Select from tlie follo�ving: <br /> ,V� The conlractor idenllfied downspouls or other drainage Ilines thal were connected to my sewer <br /> line(behveen my house and the inslalied device) and removed, or rerouted them. <br /> � To my knowledge, my property has no downspouts or other,drainage connected to my sewer lir�e <br /> (between my house and the installed device). <br /> �There are downspouts or other drainage lines connected to my sewer.lins (behvicen my house <br /> and the installed device). I understand lhal leaviny these conneclions creates a risk of(looding <br /> and I accept that risk. <br /> Signature _ _ Date � �/ lI <br />