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�/�'� Backwater Prevention Device Reba4e Program <br /> ���,�,T Rebate Application Form <br /> �--- <br /> Property Owner Name: � ✓�l ��(��./�- _ �— ' <br /> Inslallation Address:�,'-����f,l,r'�P/1 �UQ <br /> ciry:�,J L�j^f /-�L--State:_l�U�---Zip:��c�('J � <br /> Mailing Address (ildiflerentf. ���jj,� <br /> City: State: Zip: <br /> Email: Y� o�l � arl fz ���Gl/A ,Occ, nHlPhone: ( �y,�.fd/o /d87 <br /> av <br /> Total Cost to Install Device ((rnm contractor invoice): $�y�y <br /> Please verify the following: <br /> �am the owner of the property where the backwater prevention device was installed. <br /> r�worked with the coMractor to determine the location for the backwaler prevention device and <br /> understand thal the decision regarding the location of lhe device was mine. <br /> `�My conlractor instrucled me how to access, inspect, and maintain lhe device. <br /> �understand that I am responsible tor maintaining lhe backwaler prevention device and keeping <br /> i In good working order, unless it is installed in the city righl-of-way. <br /> If I sell my property, I will make petenlial buyers aware of llie back�vater prevenlion device and <br /> the need lo inspecl and maintain it on a regular basis. <br /> �am enclosing all of the necessary papern�ork(uso the yellow Rebale Submittal Checklist). <br /> Selec trom the following: <br /> The conlractor idenli(ied downspouts or other drainage Ilines that were connecled !o my sewer <br /> line(belween my house and �he inslalled device)and removed, or rerouled Ihem. <br /> ❑ To my knowledge, my property has no downspouts or other drainagc connected to my sewer line <br /> (behveen my house and the installed device). <br /> . ❑ There are downspouls or other drainage lines connecled to my sewer line(between my house <br /> and lhe inslalled device). I understand that leaving lhese connections creales a risk of(looding <br /> and I accepl that risk. <br /> Signature����[/7"I Dafe �� S <br />