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��� Backwater Prevention Device Rebate Program <br /> �'��.,._ Rebate Appiication Form <br /> .�y«„ <br /> PropeAy Owner Name: I v� �C. C�PAv-C <br /> Installation Address: / �/d � rC ✓G�«°/� G""` <br /> aiy: �✓'��'� State: G✓I� Zip: -1�2v/ <br /> Mailing Address(il diRerent): <br /> City: State: Z'�P� <br /> Email:��"��C I Pay{��w�ti �� � CV,,,,� Phone:(�`� �� 3 s� <br /> 24`��- �- <br /> Total Cost to Inslall Device (from contractorinvoice): $ - <br /> Please.veriry the following: <br /> ' �J I am the owner of the property where the backwater prevention device was instailed. <br /> � �I worked with the wntractor to determine the location for the backwater prevention device and <br /> � undersland that the decision regarding the location oF the device was mine. <br /> i �contractor instructed me how to access,inspecl,and maintain the device. <br /> � �I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it'is installed in Ihe city right-of-way. <br /> � IF I sell my property, I will make potentiel buyers aware of lhe backwater prevention device and <br /> Ihe need to Inspect and mainlain it on a regular basis. <br /> I am enclosing all of the necessary paperwork (use the yellow Rebate Submitlal Checklist). <br /> � <br /> Select from the following: • <br /> � The contractor identified downspouts or olher drainagc Ilines that were connec;ed lo my sewer <br /> line(between my hour �and the installed device)and removed, or rerouted them. <br /> i �To my knowledge,my propeAy has no downspouts or other drainage connected to my sewer line <br /> (between my house and ihe installed device). <br /> , ❑ There are downspouts or ollier drainage lines connected to my sewer line(between my house <br /> � and the�installed device). I understand that leaving these conneclions creates a risk of flooding <br /> � and I accept that risk <br /> i <br /> f • Signature �G�- Date �� �� z�Y <br /> � <br /> i <br /> If <br /> I <br /> i <br /> � � -- ------------- --- --'--- -..- ._ _.� <br />