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�,�/� Backwater Prevention Device Rebate Program <br /> �� Rebate Application Form <br /> Property Owner Name:���C & � V V v' � � <br /> Installation Address:���(�,�,(�� � � _ <br /> Ciry: G V�"Cil-�- Stale:�/'�Zip: �11 C�/I <br /> � Mailing Address(il diHerenf): <br /> Ciry: State: Zip: <br /> Email:?� • rl��tM ���r•�e� Phone:�Z��✓ ! '�Z� O <br /> Total Cost to Install Device(from confractorinvoice):$ <br /> Please v rify the following: <br /> am t wner of the property where the hackwater prevenGon device was installed. <br /> I worked with the contraclor to detertnine the location(or the backwater prevenlion device and <br /> undersl that the decision regarding the locafion of the device was mine. <br /> y contractor instructed me how to access,inspect,and maintain the device. <br /> / <br /> [�fundersta��d that I am responsible for maintaining the backwater prevention device and keeping <br /> it in ocl working order,unless it is installed in ihe city right-of-way. <br /> If 1 sell my property, I will make potentlal huyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> am enclosing all of the necessary paperwork(use the yellow Rebate Submi:tal Checklist). <br /> Selectfrom the(ollowing: <br /> ❑ The contractor identified downspouts or other drainage Ilir�es thal were connecled to my sewer <br /> line between my house and the installed device)and removed, or rerouled fhem. <br /> To my knowledge,my property has no downspouls or olher drainage connected to my sewer line <br /> (between my house and the insfalled device). -- � -- <br /> ❑ There are dowmspouts or other drainage lines connected to my sewer line(between my house- . - - <br /> and the installed device). I understand that leaving these connections creales a risk of flooding <br /> and I aceept Ihat risk. <br /> Slgnature_,�� Date ���.7//Y <br />