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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: /v! /� /��� `, �./'� �c �� <br />Inslallation Address: ��3�� �� /�Jl[ 7�. __ <br />City: L�/O�C G-%%r Stafe: �a Zip:� ��� <br />Mailing Address (if dif(erent): ��� �l/ � ����%� <br />Cify: ��C S h'�(C�i.�S State: C..t/� Zip:��SCJ <br />Email: � i1� iC � P O�L� r� Phone: ( ) y%S 3y y$"3 <br />�_.�___. _ _ <br />Tolal Gost to Install Device (�rom confractorinvoice): $ <br />Please verlfy the following: <br />I am th� owner of ihe property where the backwater prevention device was installed. <br />worked with the conlractor to delermine the location for the backwater prevention device and <br />understand that the decision regarding the location of lhe device wos mine. <br />y contractor instructed me hav to access, inspect, and maintain the device. <br />I understand that I am responsible for mainlaining lhe backwater prevention device and keeping <br />d in ood working order, unless it is inslalled in the city right-of-way. <br />I( I sell my property, I will make potential buyers aware of lhe backwater prevenlion device and <br />the nee to inspect and maintain it on a regular basis. <br />[ am enciosing aii of the necessary papenrvork (use lhe yellow Rebate Submillal Checklistj. <br />Sclect from the following: <br />❑ The coniraclor identified downspouts or other drainage Ilines that were counected to my sewcr <br />line (hetween my hause and Ihe installed davlce) and renwvrd, or rerouteci Ihem. <br />�o my knowledge, my properly has no downspouts or olher tlrainage coniiected to my sewer line <br />(between my housc and the inslalled device). <br />�] There are downspouls or other drainage lines connected to my sewer line (belween my house <br />�nd lhe inslalled device). I understand lhat leaving these connoclions croatos a risk of flooding <br />and I accept lhat risk. <br />/',/ , 6 //l/2�/� <br />Signafure ��"�- C�te / <br />—"—f—:-� <br />