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_� <br />� <br />� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Propert� vner Name: W 1 �'�' 14-�Y� `r D�rnc.V � LO N C�_ <br />I1 p d <br />Installation Address: `� � Z �k-C ��e-�' /'i�^f- <br />City: ����'"�'-� state: U�/G zip: a g Zd I <br />Mailing Address �il diHerenf): --�- <br />City: Stale:. _ Zip: <br />Emaii: _ _ Phone: ( ) _ <br />Tolal Cost to Install Device (lrum confracfor invoiceJ: S <br />Please verify the following: <br />[�I am the owner of the property vrhere the bac4cwater prevention device was installed. <br />�'I,worked with the contractor to determine the iocation f�r ihe backwater prevention.device and <br />understand that'he declslon.regarding :ne location of the device was mine. <br />��My conlractor instructed me how to access, inspect, and maintain the device. <br />tlwnderstand•that I am responsible for maintaining the backwater prevention device and�keeping <br />it in good working order, unless it is installed in the city right-of-�vay. <br />[�IF I s=11 my property, I will make potenlial buyers aware of the backwater prevention device and <br />the need to inspect and.maintaln it on a regular basis. <br />��am.enclosing all of the necessary paperwork (use the yellow Rebate Submiftal Checklist). <br />Select from the following: <br />❑ The coniraclor identified downspouts or other dralnage Ilinos that were connected to my sewer <br />line (between my house and lhe installed device) and•removed, or rerouled�them. <br />❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(b�tween;my house and lhe installed devicej. <br />[�' There are do�vnspouts or other drainage lines connected to my sewer line (between my house <br />and 1he Installed device). I understand that leaving these connectlons creates a risk of tlooding <br />and�l accept that risk. <br />Slgnature J��`^�'"' .� Dafe I-�_f - l S <br />