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4 Backwater Prevention Device Rebate Program <br />zur Rebate Application Form <br />Property Owner Name: //(�'1(!)t t J Opt <br />/I)'o-L <br />Installation Address: _J (O Ko r-{e-e f'Q <br />City: a /f Stale: 64M —Zip: Q (�ao I <br />Mailirg Address (if different): tp �I tastl/ie`i J NC <br />City:State: Zip: <br />Email: iAc_ryinroccMxcrSil7PPhone7�1�cZ0�2t <br />r <br />Total Cost to hrstall Device (tram contractor invoice): $ <br />Please verify the following: <br />K I am the owner of the property where the backwater prevention device was installed. <br />(}� 1 worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />My contractor instructed me how to access, inspect, and maintain the device. <br />� understand that I am responsible for maintaining the backwater prevention device and -keeping <br />t in good working order, unless it is installed in the city right-of-way. <br />�j If I sell my property, r will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage (lines that were connected to my sewer <br />line (between -my house and the installed device) and removed, or rerouted them. <br />To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (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 />Signatur� / Date <br />