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�,�}� Backwater Prevention Device Rebate Program <br /> �'��— Rebate Application Form <br /> iw��,rr„ <br /> � <br /> PropertyOwnerName: �i1,d�•�tY C�id9p.tl�f, �4/�7�1.� <br /> Inslallation Address: �O �D �.lE(.h.� _ <br /> City:��CJ� State: N�Zip:_�D�� <br /> Mailing Address(if diNerent): <br /> City: S�ate: Zip: <br /> I Email: ���1L-�2 J �fUrITiP.� � �M Phone (�Zb) ��V o96g <br /> Total Cosl fo Inslall Device (/rom contractorinvoice): 5 <br /> Please veri(y the following: <br /> �am the o�vner of the property�vhere the back�vater prevention device was installed. <br /> !'� . <br /> � I worked with the coMractor to determine lhe localion for the backa�ater prevention r�evice and <br /> � understand that the decision regarding the localion of the device was mine. <br /> � My contractor instructed me ho�v to access, inspect, and maintain the device. <br /> I understand lhat I am responsible for maintaining the backwater prevention device and keeping <br /> it in good vaorking order, unless it is installed in the city right-ot-way. <br /> �I(I sell my property, �will make polenlial buyers aware o(the backwater prevention d?vice and <br /> lhe need to inspect and maintain il on a regular basis. <br /> ❑ I am enclosing all of the necessary papenvork (use the yellow Rebate Submillal Checklisl). <br /> Se�ect Irom the fo!luwing: <br /> The conlractor identified oownspouts or olher drainage Ilines Ihal�ti-ere connected to my sewer <br /> � line(behve��n my house and the installed device) and removed, or rerouted them. <br /> � To my knowledge, my properly has no downspouts or olher drainage connected lo my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer line(behveen my house <br /> and the inslalled device). I understand thal leaving these conneclions creates a risk of flooding <br /> and I accept that risk. <br /> Signatare�� F—�^'�__ __ Date '��' �J _ <br />