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�,�}�► Backwater Prevention Device Rebate Program <br />��— Rebate Application Form <br />.,.- �,�„ <br />� <br />PropeAy Owner Name: � �'1 r� � �/ L'_✓� <br />Inslallation Address �� � � ��'�'!n � a ����' • <br />City: <br />htading Address (i(diflerent): <br />City: <br />State: JW � _ T_io �! p � <br />�n7�= <br />Slate: <br />Zip: <br />Email� CcZ��7 �i6✓ F�nOfS �'Cvn���tsf //r��no�e cY25>_25?-5rf/4� <br />1 otal Cost to Inslall Devicc (Irom contracrorinvoice): 5 � n C ,�� <br />Plcasu verify the following: <br />(� I am lhe ovmer of the property where Bie backwaler prevention device w�s installed. <br />7` <br />� I worked with the contractor lo determine the localion (or ihe backwaler prevention device and <br />undersland thal the decision regarding llie IocaGon ol the device was mine. <br />'� My contraclor insUucled me how lo access, inspect, and maintain Ihe de�ice. <br />� I understand Ihat I am responsible for maintaining the baclnvater prevenlon device and keeping <br />it in good workiny order, unless it is installed in Ihe city right-of-way. <br />�j�y �f I sell rrry property, I will make potcntial buyers aware oi the bzckwater prevention devicc and <br />Ihe need to inspect and maintain it on a regular basis. <br />❑ I am :.-�!osiny all o( Ihe necessary papeivrork (use the yeliow Rebale Submittal Checklisl). <br />Soloct lrani the followi��y: <br />� Tl��c �anlraclor identified downspouts or olher drainage Ilines that were connected to my se�mr <br />� line (between my house and the installed device) and removed, or rcrouled lhem. <br />1� To my knowledge, my property ha : no downspouls or oUier diain2ge connecled to my sewer linc <br />�� (hetween my house and Ihe inslalled devicc). <br />� There are downspucts or olhe� drainage lines connecled to my sewer line �between rny house <br />� l and Ihe installed device). I undersland that leaving these connedions creates a risk of flooding <br />and t accept thal risk. <br />Signature�*'z""-- �� ��i�"''-� Date �� �J _ <br />