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�, <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />PropertyOwnerName: Qoa^M �� CoQr'a _ <br />Installation Address: 2 V o'Z V� RC-, � r�� A,��, <br />City: �vf�'� State: 4�" _� <br />Mailing Address (if diflerenf): I('� �� ��'"'� <br />City: WIT��� State: �i✓`� <br />Email: AO�Gr+2cobb � (�w�a�(.�o... <br />Total Cost to Install Device (Irom confractorinvoice): $ <br />9t�2�1 <br />�nJ�. <br />Zip: Q 6oTiv <br />Phone: ( 2o1y �f % • � y=/ <br />Plea e verity the following: <br />(�am the owner of tho property where the backwater preventlon dovlce was installed. <br />[�I worked wilh the conlrador lo determine fhr, locatlon for the backwaler prevonlion davice and <br />understand tha' the decision regarding Ihe location oi the device was mine. <br />[�My contraclor instrucled me how lo access, inspecl, and maintain lhe device. <br />�understand that I am responslble lor malntaining Ihe backwater prevenlion device and keeping <br />it' good working order, unless it is installed In lhe city right-of-tivay. <br />[ If I sell my property, I wlll make potential buyers aware ol the backwater prevenllon device and <br />Ihe need to inspecl and malnlain it on a regular basis. <br />[�am enclosing all of the necessary paperworic (use Ihe yellow Rebate Submlttal Checkllst). <br />Select (rom the following: <br />� The contractor idenllfied dow�spouls or o�her drainage Illnes Ihal were connecled lo my sewer <br />Ilne (belween my house and Ihe installed device) and removed, or rerouled Ihem. <br />L�To my knnwledge, my property has no dovmspouls or other drainage connected to my sewer Ilne <br />(belween my house and the Inslalled devi�:�). <br />❑ There ere downspouls or other dralnage I�nes connaded to my sewer linc i belween my house <br />and the installed device). I understand thal leaving these connections creates a risk ot Oooding <br />and I accepl lhat risk. <br />Signafurc_�_ _ Date 4 �(���� <br />I <br />' ; <br />' <br />