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Backwater Prevention Device Rebate Program <br />Rsbate Appiication Form <br />PropertyOwnarName: cTb6eP� �� 5�ta-w✓1� Z�af� <br />Installation Address: 2�'17 �6�k�-�'a-l1eY' /�Ve • <br />City: �1.�►'t- <br />State: W�14 _ Zip: �Z �%i <br />MailingAddress(ifdiffer�nt): ��g3� ��a�".t�.. N� <br />c��y: (�ke ro�esf (�vk _ state: W�4 z�p: q��s 5 <br />Email: r6�a V L�� Vv�a t�• �0 ✓� Phone: (t{�j 9 7 I-(� 7 I 1 <br />Total Cost to Inslall Device ((rom contractor invoice): $ 2S0(i • 6��1 _ <br />Please verify the following: <br />� ro�o„�, p.o�,,r*� o�,,,�.d �Z rao n.,.,,�.. �fI�TT <br />"1''v.+�- i <br />[�I am the o�vner of the property where the back�vater prevenGon device was installed. �� �;,,�,.0 <br />QJ I�vorked with the contractor to delermine the Iocation for the backwater prevention device and� ri/q�IS <br />understand that the dEcision regardir.y the locat'on of the device was mine. <br />[rj My contractor inslructed me how to access, inspect, and maintain the device. <br />j� I understand lhat I am responsible for mainlaining the backwaler prevention device and keeping <br />il in good working order, unless il is installed in the city right-of-�vay. � <br />[�If I sell my property. I will make potential buyers av�are of the backwater prevention device and <br />the need to inspect and mainlain it on a regular basis. <br />dI am enclosing aIl of the necessary papervrork (use the yello�v Rebate Submittal Checklist). <br />Select from the following: <br />j-] The contr�ctor identified downspouts or other drainage Ilines t�tial were connecled :o my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />[�To my knovAedge, my property has no downspouls or other drainage connecled to my se�ver line <br />(behveen my house �nd lhe installed device). � <br />❑ There are downspouts or other drainage lines cannected to my sewer line (behveen my house <br />and lhe installed devlce). I understand that leaving these connections creates a risk o( Oooding <br />and I accepl that risk. <br />siynature-�'��.f��G �_ Date /i - 6 / 5 <br />