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Backwater Prevention Device Rebate Program <br />E,, Rebate Application Form <br />Property Owner Name: <br />n / l <br />) �`i� I'�h' %���f ��� <br />.�., <br />� Installation A�ldress <br />I <br />� Cily <br />Mailing Address (il differenf) <br />a�y: <br />Email: <br />Slate: <br />State: <br />Total Cost lo Install Device (fran confractor invoice): 5 <br />Please verify the following: <br />Zip: <br />Pho,�e: ( ) <br />� I am the o�mer of the property �•�here the backwater prevention dev�ce was installed. <br />�v�orked with the contraclor to determine the location for the backwater prevention devicz and <br />understand that the decision regarding the localion of the device v:as mine. <br />� My contraclor inslructed me ho�•� to access, inspect, and maintain lhe device. , <br />'� I understand that I am responsible for mairtaining the backwater prevention device and keeping <br />it in good working order, unless it is installeo in the city right-of-�•��y. <br />j� If I sell my property, I v�ill make polertial 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 ot lhe ne�essary papenvork (use the yellov.� Rr : Subnntt2l Checklist) <br />Select from the following: <br />❑ The contractor idenlified do�vnspouls or olher drainage Ilines thal were connected to my se�ver <br />line (behveen my house and the installed device) and removed, or rerouted them. <br />� To my knowledge, my property has no do�vnspouls or other drainage connecled to my sewer I�ne <br />(behveen my house and the instalied device). <br />❑ There are downspouts or other drainage lines connected lo my sewer line (between my house <br />and lhe installed device). 1 understand thal leaving these connections creates a risk of flooding <br />and I accept lhat risk. <br />Signat e Date 5�1'"��r <br />