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� Backwater Prevention Device Rebate Program <br />Rebate Appiication Form <br />Property Owner Namc: �l Kl KJ � Jl�i.i�Q,✓�' • <br />InS�alla�t Addr255: �� /� /-�,'•� <br />Cily. S,r(:9 State Zip:_ Zd <br />tvt�iling Address lildiNerent): � _ <br />Cily: <br />State: Zip: <br />Gmail: Phone:(`�1S) �� _9U <br />Total Cost to Install Device (6om conVacror invoiceJ: S�,. <br />Plcase verify the following: <br />�/� I am Ihe owner of Ihe properly where the �ackwaler prevention device was installed. <br />��I worked �vi h the contrador to delermine the localion (or Ihe backv�ater prevention device and <br />undersland thal Ihe decision regarding the location of Ihe device vaas mine. <br />� My contra�lor instructed me how to access, inspect, and maintain the device. <br />�[�] I undersland that I am responsible (or maintaining Ihe backwater prevection device and heeping <br />d in good working order, unless il is insialled in the ciry iighl-of-way. <br />� If I sell my property, I will make potential buyers aware of Ihe backwater prevenUon device and <br />lhe need to inspect and mainlain it on a regular basis. <br />[—j� am enclosing all of the necessary papervvork (use ihe yellow Rehate Subrnittal Checklisq. <br />/ <br />Select from the following: <br />❑ The conlracror idenlified do�vnspouls or othei drainage Ilines that were ccnnected to my se�ver <br />Ilne (hebveen my house and the mslalled device) and removed, or rerouted them. <br />Y I To my knowledge, my property has no c'ownspouts or olher drainage connectetl lo my se�ver tine <br />�� (behveen my hause and lhe ins�alled device). <br />❑ There are downspouts or other drainage lines connected to my sevrer line (be6veen my house <br />and Ihe installed tlevite). I understand Ihat leaving ihese conneclions r.rcates a risk o( Oooding <br />and I accepl that risk. <br />Signaturc� Dafe � 2� �� <br />