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Backwater Prevention Device kebate Program <br />Rebate Application Form <br />Property Owner Name: �SRP �+ a.+� �$�l a.�-uN a z�4 J <br />Installation Address: .2�23 �6�-1�-����-� � Qr��/Q - <br />City: EEVe /e.t� _ state: �f�_ zip: �l5'�zvl� <br />Mailing Address (il different): ��$�3� '-1 a�� ��- N� <br />cry: LakeF'or�sf- f�avk State: �✓� z�p: ��55 <br />Email: t'd�kaV�-���wi4/I •cDrh Phone:(Y25j 97l-�%�l <br />Total Cost to Install Oevice (from contre:tor invoice): $_ i—ZSi. � 3 <br />ulc h �' f°ro�a°/M, �'."".cr �2 <br />Please verify the following: � <br />�}�,�„..?,.. vf341S <br />�t�1M4 IA �/ <br />� am the owner of the property where the backa;ater prevention device �vas iostalled. �il�.�, <br />Q <br />[�I worked with tho contractor to determine the location for the backwater prevention device and <br />underslard fhat the decision regarding the localion of the device �vas mine. <br />�ti1y contractor instructed me hotv to access, inspect, and maintain the device. <br />[,�'I 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 />[�If I sell my property, � �vill make potential buyers aware of the backwater prevenlion device and <br />lhe neeo to inspect ard maintain it on a regular 6asis. <br />[,�i am erclosing all of the necessary paperwork (use the yellarr Rebate Submittal Checklist). <br />Select from the following: <br />❑ The conlraclor identified doevnspouts or other drainago Ilines that were connected to my sawer <br />line (bebveen my house and lhe.installed device) and removcd, or rerouted them. <br />[�To my knowledge, my property has no dowrispouts or other drainage connecled to my sewer line <br />(between my house and the instailed device). <br />G There are downspouls or other dreinage lines connected to my sewer lir�� (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature Date ���6 -�h� <br />00 <br />{L e.�14/ / <br />�r/a/�r <br />