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04LBackwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: / ef -P/1 X _ <br />Installation Address: /�U f V f rg l7 r � /� { <br />city:. ! z'Cf t State: IiV n ZIP:_CIE 201 —_ <br />Mailing Address (if different): <br />City; <br />Slate: <br />Email: G�,_i(ol.rtG fill � �r�i�.<c c� Phone:(4zr) T2-44s1 — <br />Total Cost to�lnsta�ll Device (from contractorinvoice): $ Z�J9 S ??- <br />Please verify the following: <br />P"I'am the owner of the property where the backwater prevention device was installed. <br />X.worked with the contractor to determine the location for Vie backwater prevention device and <br />rJf understand that the decision regarding the location of (lie device was mine. <br />L jMy contractor instructed me how to access, inspect, and maintain the device. <br />utnderstand that 1 am responsible for maintaining the backwater prevention device and keeping <br />iin good working order, unless it is installed in the city right-of-way. <br />^ II sell my property, I will make potential buyers aware of the backwater prevention device and <br />v the need to inspect and maintain It on a regular basis. <br />(;(am erclosino all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Hines 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 1 accept that risk. <br />Signature Date <br />