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�� <br />i,�/� Backwater Preventic�i Device Rebate Program <br />^►'��1 Rebate Application Form <br />M/,[Y ¢T. <br />,_y <br />Property Owner Name: sY v� � '�� � n 5 o r <br />Installalion Address: ��� S 1�-v LkGtG� �� <br />City: �� State: __� _ Zip: �/� ZG � <br />Maiting Address (iI dif/erenfJ: <br />City: — _ State. _ Zip: <br />Email: <br />Tolal Cost to Install Uevice (Irom confracforinvoice): $ <br />Please verify the followfng: <br />Phone:( ) <br />� t am the owner of U s property where the backwater pr�vention device was installed. <br />(� I �vorked w;th lhe conlractor to determine the Iocalion for lhe backwater prevenlion device �nd <br />undcrsland lhat lhe decision regarding the location of the device was mine. <br />(�jj My contractor instructed me how lo access, inspect, and maintain Ihe device. <br />� I understand thal 1 am responsibie for mainlaining the 6ackwater prevention device and keeping <br />il �� good working a�er, unless it is installed m lhe city right-of-way. <br />($ If I seli my property. I�vill make polential buyers aware of ihe backwaler prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�}� I am enclosing all of lhe necessary papen•.ork (use ihe yellow Reb.�te Submdtal Checklisl). <br />Select from the following: <br />[� The contractor identitiad do•.vnspouts or olher drainage Ilines lhat were conna�cled lo my se�ver <br />line (bet�veen my house and lhc inslalled device) and removed, or rerouted them. <br />� To my knowledge, my property has no downspouts or olher drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There a�e downs�:outs or olher drainage lines connected to my sewer line (between my house <br />and the inslalled device). I understand that leaving thesc conneclions creates a rlsk of flooding <br />and I accept that risk <br />� . � <br />SignaNre �a�,�.�%� l.�L����^� - Date .�" / d �/ � <br />� (I <br />