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�� Backwater Prevention Device Rebate Program. <br />�w✓�,,. Rebate Application Farm � <br />�-- - <br />Property Owner Name: <br />InslallationAddress: '�/-aLUl.f� <br />City: �l'�-T State:. <br />L� <br />Mailing Address (i(diNemrt): <br />City: ___ _ State: ---� �Z,,�,�P'---- <br />Emai1:=,T-[�L�n�'�� �i /,uvV`C' `+��J�r�he ( ) �.'S�"�—�DZS �� <br />Cn.U_ <br />Total Cosl lo Inslall Device (Irnm confractorinvoice): $_?i ��e ' <br />Please verify the foliowing: <br />�am lhe owner of ihe property where the backwater prevention device was installed. <br />�,. I worked wilh lhe contracior to determine the localion for the backwaler pr�vention dovice and <br />untlerstand thal lhe decision regarding the Jocation o( the Aevice was mine. <br />i <br />���;Vly conlraclor inslructed me How lo access, inspect, and mainlain lhe device. <br />� I undersland ihet I am responsible for maintaining the '�ackwaler prevenlion device and keop'�g <br />it in good working brder, unless il is instaUed in the city right-of-way. <br />�i 'If I sell my properry, I v+ill make potenlial buyers aware of ihe backwaler p�evention device and <br />Ihe need to inspect and maintain it on a regular basis. <br />❑ I am enclosinc� all of O�e necessary papenvork (use the yeilow Rebate Submittal Checklist). <br />Select irom the tollowing: <br />❑ The conlractor identified downspouls or oUier drainagc Ilines thal were connected to my sewer <br />line (between my house �nd Ihe inslalled dr,vice) and removed; or. rerouted lhem. <br />�_ To my knowledye, my proporly has no dovmspouls or olher drainago connucled to my sewer line <br />(hetween my house and the instalfed device). <br />❑ There are downspouls or other drainago lines connocled to my sr.tiver line (belwee� my house <br />and lhe installed device). I understand lhat loeving lhose connec;ions creates a risk o( Ilootling <br />and I accepl lhat iisk. <br />Slgnaturo `�L .tii2� �ooc� Date �� ' � . -u� J <br />, `� <br />