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� Backwater Prevention Device Rebate Program � <br /> ,�,�„ Rebate Application Form <br /> r--�r �/1�o= � — -- <br /> Property Owner Name: �C(�� �er✓ t, � ! � <br /> Installation Address� ��D� �JC�l2 <br /> City: ✓ ✓v Zr^�� State. _ �}_}f�" Zip <br /> Mailing Address (if differnnlJ: <br /> City State: Zip: <br /> Email: _._ Phone: ( ) <br /> Total Cost lo Install Device (nom con(raclorinvoice) S <br /> ------- - ----J <br /> Please verify the tollowing: <br /> �am Ihe owner of the property where the back�vater prevention device was installed. <br /> V'�I worked with the con�rador to determine the localion for the backwater prevention dtwce and <br /> imderstand thal the decision regarding the Iocation of the device was mine. <br /> dMy contrac�or instructed me how lo access, inspect, and mainlain the device. <br /> i <br /> �] I understand that I am responsible (or mainlaining Ihe t�ackwater prevenlion device and kecping <br /> d in good working order, unless it is instaiied in Ihe cdy right-oLway <br /> Q It.l sell my property, I will make pofential buyers aware of the backwater preventinn device and <br /> the need lo inspect and maintain it on a regular basis <br /> [�'I am enclosing all o(lhe necessary papenvork(use the yellow Rebale Subrnillal Checklist). <br /> Select(rom the following: <br /> ❑ The con(raclor identified doe+nspouts or other dn,inage IGnes Ihal �vere connecled lo my sewer <br /> line (bclwcen my house and the installed dev�ce)and removed, or rerouted them. <br /> []�To my knowledge, my property h�is no do�vns:�outs or other dramage connecled to my sewer line <br /> (behvicen rny house and lhe inslalled device) <br /> ❑ There arr. downspouls or other drainage hnes connecled to my sewcr hne (between my howe � <br /> and.the inslalled device). I understand Ihal leaving Ihese connections creates a risk of(looding <br /> and I accepl(ha1 risk. <br /> Signaturc � � Date �l /��f� <br />