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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name:�'Y1�1 V'1�� ��� Y�1^'C l`� <br />Inslallation Address: � � � �V . <br />l/1�--T State: �'� <br />City: =� <br />Mailing Address (i(dilferenfJ: ` <br />Cily: <br />State: <br />Zip: a' �! !? � <br />Email: _ ___,u_ Piione: ( ) <br />Tolal Cos! to Inslall Device ((mm contractorinvolce): $__ �� L( � t�' =�f <br />Please verify the following: <br />�L am the owner o( ihe propeAy where lhe backwater prevenlion device was installed. <br />[�}�worked with the cronlractor lo determine lhe loca�ion for the backwater prevention device and <br />understand lhal the decision regarding lhe localion of thc device was mine. <br />1y wntractor instructed me how fo acc�ss, inspect, and maintain tho device. �- <br />[�understand thal I am responsibie for maintalningthe backwater prevenlion device and keeping <br />it in good wo;king order, unless it is installed in Ihe city right-of-way. <br />��I sell my property, I will make,pole�tial buyers aware oi the backv+ater prevention device and <br />j tt�0� need to inspect and mainlaidil on a regular basis. <br />� I am enclosing all of Ihe necessary papenvork (uze the yellow Rebate Submiltel Checkl�sl). <br />Srlect from the following: <br />;] The coniractor iden6fied downspouls or olher drainage Ilines tlial were connected lo my sewer <br />line (between my house and the installeci devicc:) and removed, or rerouted lhem. <br />� To my knowledge, my properiy has no downspout: or olher dramage connecled to my sewer line <br />(betwocn my house a�d tha installed device). <br />❑ There are downs��outs or olher drainage Iines connected to my sewer line (between my house <br />and lhe inslalled device). I undersland that leaving these connections creates a nsk ol floodinfl <br />and I accepl lha[ risk. <br />Date_�-��-�b <br />