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�n� Backwater Prevention Device Rebate Program <br /> C�'� Rebate Application Form <br /> �.>.�.. <br /> Property Owner Name: p�/!�la S�to�"Y,rn <br /> Installation Address: /l/SI 2GcGk P/ <br /> City: FVe/et�f' State: tn//� z�p: 9ga�l <br /> Mailing Address (if dilferent): <br /> Cily: Stale: 7_ip: __ <br /> ' Email: �Sec�rna.n��[e�,cc� Phone: (4�)� l�/a9 <br /> Total Cost to Install Device (from confractor invoiceJ: $_�So�.�� <br /> Please verify the(ollowing: <br /> �1 am the owner of the property where the backwaler prevention device was installed. , <br /> �'I worked wilh lhe contrector to detertnine the location for ihe backwater prevention device and <br /> understand that the decision regarding the location of the device was mir.e. <br /> , ,{�My contraclor instructed me how to access, inspecl,and maintain the device. <br /> �I understand thal I am responsibte for maintaining lhe backwater prevenlion device and keeping <br /> il in good working order, unless it is installed in ihe city righl-of-way. <br /> � If I sell my propeAy, I will make potential buyers aware of lhe backwater prevenlion device and <br /> the need to inspect and maintain it on a regular basis. <br /> � 1 am enclosing all of the necesrary paperwork(use the yellow Rebale Submiltal ChecklisQ. <br /> Select fram the following: <br /> ❑ The conlraclor idenlified downspouts or olher dr�inage Ilines ihat were connecled to my sewer <br /> line (between my house and the installed dcvicc)and removed, or rerouted lhem. <br /> ❑ To rny knowledge, my property has no downspouls or other drainage connected to my sewer line <br /> (between my house and lhe inslalled device). <br /> �There are Aownspouts or olher drainage lines conneded lo my sewer line (belween my house <br /> and the installed device). I undersland that leaving these conneclions creates a risk of 1looding <br /> and I accepl thal risk. I <br /> � <br /> Signature '/ i�+�L1� �"�7�'l.r4r�—Date /�fL. �./�H+ • .�/.7 <br />