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�. <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: �`t��=�� �'�L��'"� <br />InstallationAddress: �`z?n U.rn,:...,� /lvir-�-- <br />c�ry: /���.,,�r-,- 'Stale: l.�fs7-. z�P� `iF1261 <br />Mailing Address (if diKerenf): <br />City: <br />State: <br />Email: ICc3�TN��t U�e,�,�N � r+-� Phone: ('�ZSj 772 — S�7B <br />Tolal Cost lo Install Device (Irom contractor invoice): S ZQ'8� ��9" <br />Please verify the following: <br />[J I am the owner of the property where lhe backwater prevenlion device was installed. <br />�worked with the contractor to dele�mine the localion tor the backwater prevenlion device and <br />understand th2l the decision regarding u�e locatinn of the device was mine. <br />�My contractor instructed me how to access, inspect, and maintain the de��ice. <br />0 I undersland thal I am responsibte for maintaining the backwater prevention device and keeping <br />it in good working crder, unless it is installed in the city right-or-way. <br />If I sell my property, I will make potential buyers aware ot the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�am enclosing all,of the necessary papenvork (use the yelloH� Rebate Submiftal Checklisl) <br />Select from the following: , <br />(I�e conhactor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (bel���een my house and the installed davice) and removed, or rerouted them. <br />�o my knowledye, my propeRy has no downspouls or other drainage connected to my sewer line <br />(between my' house and the installed device). <br />[� There are downspouts or other drainage lines connected to my sewer line (bebveen my house <br />and the installed device). I understand that leaving Ihese connections creates a risk of flooding <br />andlacceptthatrisk. <br />x�Signature �_ Date � � <br />�, <br />