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� Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installalion Address: '� 1 t L� � l 1 GlC_.P V' Y-YI/!-� <br />City: T� V/�_-y State: � Zip: ��-- v� <br />Mailing Address (if diNerent): <br />City: State: Zip: <br />�mail: �1f�Ci��l���1�Y1/12j_1� ►7'1_�hone:(l'��Jo7�T��� <br />Total Cost to InsWll Device (Irom contrectorinvoice): $� L�d �• �� <br />Please verify the following: <br />I am the owner of the property where the backwater prevention device was installed. <br />orked with the contractor to determine lhe location tor the backwater prevention device and <br />understand lhat the decision regarding the loqtion of the device was mine. <br />� contractor Instruded me how to access, inspect, and maintain the device. <br />understand that I am responsible for maintaining lhe backwater prevention device and keeping <br />it in good working order, unless ft Is installed in the city right-of-way. <br />m�sell my property, I will rrake potential buyers aware of Ihe backwater prevention device and <br />the need to inspect �nd malntain it on a regular basis. <br />❑ I am enclosing all of the necessary papenvork (use the yellow Rehale Submittal Checklist). <br />3elect from the followi�g: <br />❑ The contraclor identified downspouts or other dralnage Illnes that we2 connected to my sewer <br />line elween my house and the installed device) and7emoved, or rerouted them. <br />o my knowledge, my property has no downspouts or olher drainage connected lo my sewer Ilne <br />(tietween my house and the inslalled device). <br />❑ There are downspouts or other drainage lines conneded to my sewer line (between my house <br />and the installed device). I undersland that leaving these connections creates a risk of flooding <br />and I accept that risk. '' <br />, -- <br />_; ;. <br />?;- . <br />;: : <br />