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Backwater Prevention Device Rebate F'rogram <br />Rebate Application Form <br />Property Owner Narr <br />Installalion Address: <br />Cily: �vvr(/f� Stale: �,j;�__ Zip: <br />tilailing Address (iI diHerent): <br />City: _ <br />State <br />Q4�ZD <br />Email: � O��aG4p.{�pt,,)(� (f,oYlcl1�l'1 t�i' Phone: (3G:a 1031 %SS' i <br />J <br />Tolal Cos! to Install Device (l�om confracforinvoice): S <br />Please verify the following: <br />� I am the owner of the property where the backwater prevention Jevice was installed. <br />� I worked with the contraclor to determine lhe iocation for the back�vater prevention device and <br />understand that the decision regarding the location oi the device was mine. <br />� tvly conVactor instructed me how to access, inspect, and maintain Ihe device. <br />� I understand tha� I am responsible for maintaining ihe backwat�r prevention device and keeping <br />it in good working order, unless il is inslalled in the city right-of-way. <br />� If I sell my propeAy, I�vill make polential 6uyers aware of the bar.kwaler prevention device and <br />lhe need to inspect and maintain il on a regular basis. <br />(� I am enclosiny all o( Ihe necessary papenvork (use Ihe yetlow Rebate Submittal Checklist). <br />Select from the following: <br />� The contraclor identified downspouts or olher drainage hines that were connected lo my seNer <br />line (belween my house and the inslalled devic;e) and removed, or rerouted Ihem. <br />f� To my knowledge, my property has no downspouls or other drainage comiecled to my sea�er line <br />(between my h�use and the ir,stalled device). <br />❑ There are downspouts or olher drainage lines connected to my sewer line (between my house <br />and the installed device). I understand ihal leaving ihese connections creates a nsk of flooding <br />and I accept thal risk. <br />Signature Date �_ ��� <br />