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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Please verify the following: <br />[� I am the oti�ner ot the property where the backwater prevention device was installed. <br />[� I worked with the contractor to determine the localion for the backwater preventio� device and <br />understand lhat the decision regarding the Iocation of ihe device was mine. <br />� My contraclor instructed me how to access, inspect, and maintain Ihe device. <br />[� I understand that I am responsible lor mainlaining the backwater prevention device and keeping <br />it in good working order, unless it is instalied in lhe city right•of-way. <br />� If I sell my property, I will make potential buyers aware oi the backwater prevr:�:tion device and <br />lhe need lo inspecl and maintain it on a regular basis. <br />[� I am enclosing all oF the necessary paperwork (use the yellow Rebale Submiltal Checklist). <br />Selecl irom the following: <br />j] The contraclor identitied downspouls or olher drainage Ilines that were connected to my sewer <br />�ine (between my house and the installed device) and removed, ar rerouted them. <br />To my knowledge, my property has no downspouls or olher drainage connecled Io my sewer line <br />(hetween my house and the Installed device). <br />[j There are downspouts or other draina9e lines connected lo my se�ver line (beRveen my house <br />and the inslalled device). I underslend lhat leaving these connections creates a risk of Oooding <br />and I accept that risk. <br />� — \l <br />Signaturc '\N^ V�,'V Date <br />