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4r Backwater Prevention Device Rebate Program <br />� <br />Rebate Application Form <br />er <br />Property Owner Name: <br />Installation Address: } C�0\ 5�C•,ttnll� \)� — <br />City: I A.+-t��7 State::? - <br />Mailing Address (if different): ) Cl?1 Ir on <br />City: �r i't,C State: Zip: <br />I` 7 <br />Email: i arc, �C r ti( rrl'lir'� � � �l°^ Phone: (r'� } <br />Total Cost to Install Device (from contractor invoice): $ <br />Please verify the following: <br />'-FZf I am the owner of the property where the backwater prevention device was installed. <br />I worked with the contractor to determine the location for the backwater prevention device and <br />J understand that the decision regarding the location of the device was mine. <br />My contractor instructed me how to access, inspect, and maintain the device <br />1 understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good vroiking order, unless it is installed in the city right-of-way. <br />n�yy If I sell my property. I will make potential buyers aware of the backwater prevention device and <br />\-the need to inspect and maintain it on a regular basis. <br />I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />The contractor idantihed downspouts or other drainage (lines that were connected to my sewer <br />line (between my house and the Installed device) and removed, or rerouted them. <br />To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the Installed device). <br />There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />nature Date '5—I � 3 20 ) 3� <br />Si <br />9 _S�_ <br />