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`� <br />Backwater Prevention Device Rebate Program <br />RsbatP Application Form <br />Property Owner Name: �0.f'h'��G `• �p/tnvt �R-1'�v1 �ctM^ �T �rU S-}' <br />Installation Addrass: 2fo��1 Q6���-'��- � � Q����� • <br />a�y: Evzre <br />State: W'11 Zip: `f`�2Cf � <br />Mailing�ddress(ifdiNerenf):2�36 S� ��a�'� P�• <br />city: 5� a.N'( � 5tate: �� Zip: RS I(p �o <br />Email:✓�^�'S71�p¢T�rS ��Gb+'ta��• COMn Phone:��) 433�(133_ <br />Total Cost to Install Device (lrom contractor invoice): 5 �`� 9 ro • 31 <br />Please verify the following: <br />�am the owner of the property where the back�vater prevention device was installed. <br />� worked with ihe conlractor to determine the location for lhe backwater prevention device and <br />undersland that the decision regarding the location of the device �vas mine. <br />[�ti1y contractor instructed me how to access, inspect, and maintain the device. <br />[v�l understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />�f I sell my propeity, I will make potenlial buyers a�vare'of the backwater prevention device and <br />the need to inspect and maintain it on a regular �iasis. <br />�v I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select irom the following: <br />❑ The conlractor identifed do�vnspo�its or other drainage Iiines thal were connected lo my sev�er <br />line (belween my house and the installed device) and removed, or rerouted them. <br />[j�To my knoe�ledge; my property has no Aownspouls or olher drainage connecled lo my sewer line <br />(between my house and ttte installed device). <br />❑ There are do�vnspouts or olher drainage lines connected to my sewcr line (between my house <br />and the installed dekce�}�i understand that ving these connections creates a risk of Oooding <br />and I accept that ris ,/ ► <br />Date� � ��� <br />