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� Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: _j'�_Yl Y `�]���L�\.�.1�—_—_ --- <br />1 <br />Inslallation Address: ��� �V G� _ —r --_----- <br />'^',n l.�- z� `��Z u?� <br />City: _� VS� L.-- Slate. ---- p'— <br />Mailing Address (il dil(erent): __ -- <br />City: — -- --- Slate: Zip'_ ----- <br />Email: _ _ --- -- Phone: � �._�7 ��Z <br />Total Cost to Instail Device jfiom confraclor invoice): 5�Uc� p— -- <br />Please verify the following: <br />C�m the o�vner o( the property where ihe backwater prevention device was installed. <br />�worked �vilh the contrecror to determine the lacation for the back�valer prevention device and <br />understand thal the decision regardmg lhe location o( the device was mine. <br />1y contractor mstruded me how to aCcess, inspecl, and main�ain Ihe device. <br />��derstand that I am responsible for maintaining Ihe baclnvater prevention device and keepmg <br />it in good working order, unless it is inslalled in lhe ciry rightwf•ti��ay. <br />f I sell my property, I will make polential buyers aware of lhe backwater prevention device and <br />he nced to inspecl and maintain i! on a regular basis <br />(�1I�°�m enciosing all of lhe necessary paperwork (use the yellow Rebate Submiltal Checkh;q. <br />�r� <br />Seiect from the following: <br />� ie contraclor idenlified downspouts or other drainaye IGnes Ihal were connected to my sewer <br />hnc (nehvecn my howe and thr, installed device) and remaved, or rerouted them. <br />❑ To my knowledge, my property has no downspouls or other drainage connected to my se•.vcr line <br />(behveen my house and the inslalied device). <br />[� There are downspouls or other drainage Ilnes connecled to my sewer line (between my house <br />and �he inslalied device). I understand that leaving lhese connections r.reates a risk o( tlooding <br />and I accept that nsk. <br />SignaWrc_ �'---_--- ---- Date � 1__�t_�!— <br />