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��� Backwater Prevention Device Rebate Program � <br /> �'r�._ RebaEe Application Form <br /> ���„ <br /> ' Property Owner Neme: <br /> Instelletion Address:_�j� � — <br /> City: �.1/�r State:�1'�Zip: +-'�`� � : <br /> Mailing Address(If dilferent): , <br /> Gty: Stele: LP= -n 1 <br /> Phone:�-Or� ����� 11 � � � <br /> �,a�: �/ 3 0 <br /> Total Cost to Install Device(from contractorinvolce):$ �'7 a 1 ' - I <br /> Please verify the,following: ' <br /> I em the owner of the property where the backwater prevention device vns lrulalled. <br /> �wo�ked with lhe oo�trador to detormine Me bral'on for the backwaler preventkon device end <br /> undersland that the decislon regardl�g lhe localio i uf llie device was mine. _ <br /> ly contraclor instructed me how to access, Inspec;, end maintaln the devico• -� i <br /> understand ihat I em responslble for mainteining the backwalar preventbn devioe end kee�ing i <br /> ft in good working order,unleas It Is Inslalled in Ihe city right-of-way. <br /> f 1 sell my property,I wlll make potentiel buyers aware of lho beckwater preventlon device and � <br /> r-�Ihe rroad to freped nnd mafntnin It on a regular bnaie. � <br /> ( �7nm enclosin8 a�l of the aecessery pePon^'o�lc(use Ihe yelluw Rebale 9ubmillnl Checklist). <br /> Seloct trom the following: <br /> -�tre contreclor ldentMed downspouts or othar drainago IGnes lhat were ccnnected ro my aewer <br /> line(between my house end the insinlled device)and rernoved,a rerouled them. <br /> �my knowlodge,my pmperty hns�o downapoula or other dralnage conne�ted to my sewer lino <br /> (belween my houae enA the installed device). <br /> ❑ 7�ere ere drnmspouts or�ther dreinage Ilnes conrreded to my sewer I'me(between my houss <br /> and the installed device).1 unAerstand thal leaving these wnnedia�s creates a risk of tlooding � <br /> end 1 aocept that risk. I <br /> Signafuro Date �` � / -/S I <br /> I <br /> I <br />