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�^%�� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Properiy Owner Name:�i6ffL1 S l�0l.,�S e IJ <br /> histallation Address: U �3 � �ti'/Z�4�f- L7�• <br /> � <br /> City: �✓��� state: �(� zip: g`8�3 <br /> Mailing Address(if diflerenl): 2�3 0� WF-�.c(f �7 <br /> City: SNm l S(� State: W/Y Zip: �8�-9/0 <br /> Email: G�'o � o v� �L eo. c.�vro Phone: (�{2dj �.32-�-�Do <br /> Total Cost to Install Device (from contractor invoice): $��Go.� <br /> Please verify the following: <br /> [v�I am the owner of lhe property where lhe backwaler prevention device�vas installed. <br /> (� 1 worked with the contractor to determine the iocalion for ihe backwater prevention device and <br /> understand that the decision regarding the location of Ihe device was mine. <br /> �( My coNractor inslrucled me how to access, inspecl, and maintain the device. <br /> [,� I understand thal I am responsible for maintaining lhe backwaler prevention device and keeping <br /> it in good working order, unless it is installed in the cily right-of-way. <br /> �' If I sell my property, I will make potential buyers aware of the backwaler prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> � I am enclosing all o(Ihe necessary paperwork(use the yellow Rebale Submiltal Checklisl). <br /> Select from the following: <br /> ❑ The conlractor identified dovmspouts or other drainage Ilines that were connecled to my se�ver <br /> line (belween my house and the installed device) and removed, or rerouled them. <br /> �], To my knowledge, my property has no downspouls or olher drainage connected to my sewer Hne <br /> (between my house and the installed device). <br /> ❑ There are downspouls or other drainage lines connected lo my sewer line(belween my house <br /> and the inslalled device). I understand lhat leaving thesc conneclions creales a risk o(flooding <br /> and I accept that risk. <br /> Signafu e _Datc �'7f'� <br /> i " <br />