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C�� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: ��� �l1� � <br />-- � <br />Inslallalion Address: <br />City: <br />Mailing Address (if di�Ierent): <br />City: <br />State: <br />State: <br />r � j� � Jl <br />Zip: <br />Email: _ _ Phone: (;�%�2JZ' ✓� <br />Total Cost to Inslall Device (from contractor invoice): $� �'O c� <br />Plcase veriFy the following: <br />�j I am the owner of the prnperty where lhe backwaler prevenlion device was inslalled. <br />�1 worked with lhe conlraclor to determine the localion for Ihe backwater preveni�on device and <br />understantl lhat the decision rec�arding the location ot the device a�as mine. <br />�M conlractor instruc�ed me how lo access, inspecl, and maintain Ihe device. <br />I understand lhal I am responsible for maintaining Ihe backv�aler prevention device and keeping <br />i m good working ordcr, unless il is inslalled in thc city tight-of-way. <br />If I sell my property, I will make ^olential buyers aware oi thr. 6ackwater prevenlion device and <br />tFje need to inspecl and maintain il on a regular basis. <br />[I �am enclosing all o( the necessary paperwark (use Ihe yellow Rebate Submiltal Checklist). <br />Select from the following: <br />� The r,ontractor identified downspouls or olher drainage Ilines thal were connecled to my sewer <br />line (belween my house and the installed device) and removed, or reroided thrm. <br />�o my knowledpe, my prope�'y has no downspouls or other drainage connecled to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouls or olher drainage lines connecled lo my sewer line (belween my house <br />and the inslalled device). I understand ihal leaving these conneclions creales a risk o/ Ilooding <br />and I accept lhat risk. <br />. , . ' '.11_►_'! / 'J � ' 1c�►, � i _i Y <br />