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� Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installalion Address: ?��V �— RV l �� � '��� <br />Cily' � / `� �/� �'� State: � Zip: `YIGCJ � <br />MailingAddress(ifdiNeront)� Z���7� �ILL"l C <br />Ciry� � 1n l' I jJl V l.ti� State: ��A Zip: ��---! ri%� <br />Emai�: ��I�i�LhNDL{�'UI��1�C�Lf�n�J C'�i�7� Phone:(�fhlo3%�)iGICD <br />Total Cost to Install Device (lrom conlractorinvoice): $ ��5�/ <br />Please verify the following: <br />,� i am Ihe owner of lhe pwperty �vhere the backwater prevention device was installed. <br />�' I worked wilh the contractar to determine the location (or the backwater prevention device and <br />underst� nd �hat Ihe decision regarding the loca�ion ol the device was mine. <br />� My contractor instructed me how te access, inspecl, and maintain the device. <br />(�T I understand that I am responsible for mainlaining the backe�aler prevention device and keeping <br />it in good working order, unless it is installed in lhe city right-of-way. <br />'� If I sell my property, I will make potential buyers aware of ihe backwater prevention device and <br />lhe need to inspect and mainlain it un a regular basis. <br />�1 I am enciosing a�l of the necessaiy papenvork (use the yellow Rebate Submittal Checklist). <br />Select trom the foliowing: <br />❑ The contractor identified do�vnspouls or olher drainage Ilines that were connected lo my s=wer <br />line (beriveen my house and lhe inslalled device) and removed, or rerouted them. <br />�To my knowledge, my property has no downspouts or other drainage connected lo my sewer line <br />(beQveei� my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer Iine (between my house <br />and the installed device). I undersland that leaving these connections creates a risk of (looding <br />and I accepl thal risk. <br />�� <br />` �' <br />Sign�.fuie Dale 2(� MfaIZ IS <br />