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I � <br />' �,�,}�' Backwater �revention Device Rebate Program <br />; ^�— Rebate Ap�;lication Form <br />M�e i¢ii <br />i �—� <br />Property Owner Narr <br />Installation Address: � /f !// ' n/:9 �!c/r= <br />�� <br />City: !i�/���1_�__ Stale: !7�__ Zip:_ �J�S'2o / <br />��_ <br />Mailing Address (if di!ferent): <br />City: Stale: Zip:_ _____.__ <br />EmaiL•��'_ 1-��:_ Phone:QU�I ;JS� '��Z� <br />Total Cost to Install Device (lrom confractor invoice): 5 <br />Please verify the following: <br />� am lhe owner of the property where the backwater prevention device was installed. <br />� worked with the contrecto� lo determine lhe location for the backwater prevention device and <br />understand ihat lhe decision re3arding the localion of the device �vas mine. <br />j [/f My conUaclor instrucled me how to access, inspecl, and mainlain the device. <br />! �'I undersland that I am responsible for maintaining Ihe backwater prevention device and keeping <br />' it in good working order, unless il is inslalled in the city righl-of-way. <br />� If 1 sell my property, I�vill make potential buyers aware of lhe backwaler prevenlion device and <br />, the need to inspecl and maintain it on a regular basis. <br />� I em enclosing all of the necessary papenvork (use Ihe yellue� Rebale Submiital Cher.klist). <br />Select from the following: <br />[If The conlractor identi(ied downspouls or olher drainage Ilines lhal were connecled lo my sewer <br />line (between my house and the inslalled device) and re�noved, or rerouled them. <br />([�To my kno�vledge, my property has no downspouls or alher drainage connecled lo my sewer line <br />(between my house and the inslailed device). <br />�� There are downspouts or other drainage lines connected to my sewer Iine (between my house <br />C1 and ihe inslalled device). I understand that leaving these connecllons creates a risk of flooding <br />and I accept lhal risk. <br />Signature � Date � l� LZ <br />