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� <br />�� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Fo...� <br />Property Owner Name: ��� �� <br />Installation Address: �� � 7 �!GdSb�""" ' "� <br />Cily: (�Y��-�! State: lii%/�' Zip:����� <br />Mailing Address (if drlferent): <br />City: <br />Email: <br />Srate: <br />Phone: ( <br />Tolal Cosl to Install Device (from contracfor invoice): 5_P��9`�_1 � <br />please verify the following: <br />� I am the owner of the property where the backwaler prevenlion device was installed. <br />�f I wo ed wilh the contractor to delermine the location for the backwater prevenlion device and <br />understand lhat the decision regarding the location of lhe device was mire. <br />� My contraclor instructed me how lo access, inspect, and maintain lhe device. <br />�I understand that I am responsible for mainlaining the backwater prevenlion device and keeping <br />it in good workii �� order, unless it is inslalled in lhe city right-of-way. <br />� If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />lhe need to inspect and maintain il on a regular basis. <br />�Z] I am enclosing all �f the necessary paperwork (use the yellow Rebate Submittal Checklis;j. <br />Select from lhe tollowing: <br />�The conlractor idenlified downspouts or other drainage Ilines thal were connecled to my sewer <br />line (benveen ny h��use and the instalied device) and removed, or rerouted them. <br />[� To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(belv+een my house and the inslalled device). <br />[� There are downspouts or other drainage lines connecled lo my se�ver line (belwecn my house <br />and the installed device). I understand that leavina these connections creates a risk of flooding <br />and I accept thal risk. <br />Signature �� Date // � ��� <br />✓ <br />