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� Backwater F'revention Device Rebate Program <br />Rebate Application Form <br />�l�Av t D F_rE NQ�N LY NyF_��F <br />Property Owner Name: _ <br />I/ �7 w <br />Installation Address: _��`f _�( /R �//u/�Q __ �7 �E <br />� c�iy: Et/E�2E �_ si��e: _/t)_�._ z�� � c�� ( <br />A�lailing Address (il dillerent): <br />City. _ <br />State: <br />Zip:_ <br />Email' dfi'ssC/-!L'�V_�—��'Tl R'(� . i� /%t Phone �o�� �� - � y( <br />cro2 S �,2.7 - ( O lP � <br />Total Cos! lo Ins�all Device (from cnnfractor invoiceJ' S <br />Please verify the following: <br />� I am the oemer of the property vihere ihe backe�ater prevenlion device �vas installed. <br />�� worked �vilh Uie contraclor lo determine the location for the backwaler prevention device and <br />� u�dersland that the decision regan�ing the location of the dewce tivas mine. <br />�] My contracror instructed me how to access, inspecl, and maintain the device. <br />�.i <br />�I�mderstand that I am responsible for maintaining Ihe hackwater preven�ion device and keeping <br />it in good ��orking order, unless it is installed in the ciry ri�ht-of-way. <br />� If I sell my ��roperty. I�vill make potential buyers aware of the backwater prevention device and <br />, the need lo inspecl and maintain il on a regu�ar basis. <br />�" I am enclosing all of the necessary paperwork (use Bie yello�v Rebale Subrnittal ChecklisQ. <br />Select from the following: <br />�] The contraclor identified downspouls or olher drainage Ilines that �vere connecled lo my sewar <br />line (behvecn my house and the ins,talled device) and removed, or rerouted Ihcm. <br />�QI To my knowledge, my property has no downspnuts or olher drainage conner.ted lo my sewer line <br />(helween rny house and Uie mslalkd device). <br />[j There are downspouts or other drainage lines con�ected to my sewer Ilne (behveen my house <br />and Uie inslalled devir,e) I undersl2nd thal leaving Iliese connections creates a risk of Ilooding <br />and I accept �hal risk , <br />„ �����Lt: ����'vu'.�(X/l� Date � `J -�`S <br />Signatur�L <br />t✓� <br />