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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name:. Ec , r:,5 <br />J <br />Installation Address: 3701 4'L-A�z �&6 ' Are <br />City: State: -Zip: %-z.aj _ <br />Mailing Address (if different): <br />City: <br />State: <br />Email: Phone: (`iZS) <br />Total Cost to Install Device (from contractor invoice): $ <br />Please verify the following: <br />(a' I am the owner of the property where the backwater prevention device was installed. <br />Q 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 ^ ess, inspect, and maintain the device. <br />I understand that I am responsible: for maintaining the backwater prevention device and keeping <br />it in good workirg order, unless it is installed in the city right-of-way. <br />If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it an a regular basis. <br />[' 1 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 />-jK 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 />an <br />Signa <br />d I accept that r' <br />Pure Date �it <br />