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C�� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation Address ��_ � <br />City: �Q � Slate: <br />Zip <br />�vlailing Address (if diHerent� ��/�/Y�Q , � _ <br />Clty: <br />Email: <br />State: <br />' Tolal Cost to Inslall Device (Irom confrac(orinvoice): S <br />Please verify the following: <br />Zip: <br />Phone: ( ) i <br />yccc/ <br />(� I am Ihe owner of tha property �vhere the backwater prevention device �vas inslalled. <br />�l�- I worked wilh Ihe con(ractor �o determine ihe location for the backa�ater prevention device and <br />� underst2nd that lhe decision regarding the locaticn of the device was mine. � <br />'�vty conlraclor insUucted me hov� to a�cess, inspecl, and mainlain the device. <br />-(�,.1 understand thal I am responsible (or maintaining thr. backwater prevention device and keeping <br />i� in good tivorking order, uNess il is inslal�ed in Ihe cily right-of-way. <br />[..�L�1f I seil my property, I �vill make potential buyers a�vare of Oie bark�valer prevention device and <br />the need to inspect and maintain il on a reyular basis. <br />t�� I am enclosing all of lhe necessary p, oenvork (use the yellotiv Rebale Submiltal Checklist). <br />Select irom the following: <br />❑ The contractor idenUfied downspouls or olher drainage Ilines thal �vere connected to my sewer <br />lina (behveen my house and Iha mstalled device) and removed, or rerouled ihem. <br />o my knowledge, my property has no doemspouls or olher drainage connecled to nry sewer line <br />( ehveen my house and Ihe installed device) <br />[ j I here are downspouls or other draina�e lines connected lo my sewer line (between my house <br />and the ins:alled device). I imdersland iha� leaving Ihese connections creates a risk o( flooding <br />and I accept that risk. <br />Signature �%`--� Y �' U'!J Yu� _ Dafe �- ��— 2 l�y� � <br />