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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: _._'�EY�" ..p.LGC_—NUII�L�_ 1�C1 <br />Installation Address: __3(��_I�U��L`�Ye <br />City: Q2'1L�'�' State: �IV}-r} Zip:�['f�_ <br />Mailing Address (il dif(erent): _ <br />Cily: <br />State: <br />Emai�:_ 1'�Vr1�G�r�GGr�� mC�i)_CU�none:(�i�`� 25t�1o�17� <br />Tolal Cost to Install Device (l�m contractor invoice): S Z i`� � <br />Please verify the follov+ing: <br />N� I am tiie o�snerof the property where the backivater preventien deyice �vas installed. <br />�jl��y' I v+orked with the contractor to delermine the Iecalion for the backwater prevention device and <br />understand that the decision regarding lhe Iocalion of the device �vas mine. <br />�.15�� h1y contractor inslrucled me how to access, inspect, and maintai� the de��ice. <br />�.1ti2j� I understand that I am reaponsible tor maintaining the backwater prevention device and keeping <br />il in gocd v�orking order, u�less it is installed in tlie city riyhL-of-�vay. ' <br />�R /�')f I sell my property, I vlill make potentiat buyers aware of the backwater preven!ian device and <br />the need to inspect and maintain it on a re9ular basis. <br />,�[l,� I am enclosing all of the necessary papenvork (use the yetlo�v Rebate Submittal Checklist). <br />J <br />Soloct from the following: <br />❑ The contractor idenlified dotivnspouts or otherdrainage Ilines Uial were connected to my sewer <br />line (behveen my house and the installed dovicc) and removed, or rerouted them. <br />�� To my knotivledge, my property has no downspouts or other drainac�e connected lo rny sewer line <br />(behveen my house and the installed device), <br />❑ There are dovmspouts or other drainage hnes connected to my sewer line (beRveen my house <br />and Ihe inslalled device) I understand thal leaving these connections creates a risk of flooding <br />and t aaept that risk. <br />SJgnature N• l�rYl�( Date � 2X. 7Q� �j <br />