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� <br />Backwater Preveni:ion Devic� Rebate Program <br />Rebate Application Form <br />PropertyOwnerName: ( ,Ni I�OSS ,q�p �HONOA �/��+za��_ <br />Insl211alion Address: _ 26 O��_t_� N� �' ��`-- ��� <br />City: �_�r o c�tate: � I � _ Zip:�� 2. U I <br />Mailing Address (if di//erent): <br />Cily: Slate: _ Zip: <br />Email: C�n��Cmw�C�St "� Phone: (4Lsj z-S9— 1S'Ei � <br />Tolal Cost to Inslall Device (from ccntractor invoice): 5 �� f� •� -- <br />Please verify the following: <br />� am Ihe owner of lhe property where the backwater prevention device was installed. <br />t.f�Ll workod with the contraclor to determine the location for the backwater prevenlion device and <br />V-� u�derstand that lhe declsion regaiding the location o( the device was mine. <br />�1y conlractor instrucled me how to access, inspect, and mainlain the device. <br />I�I undersland that I am responsibte for maintaining the backwater prevention device and keeping <br />It in good �vorking order, unless it is installed In the cily right•o(-way. <br />,' If I sell my property, I will make potenGal buyers aware of the backwaler prevenlion device and <br />Ihe need lo inspect and maintain it on a regular basis. <br />�I am enclosing all of the necessary paperwork (use the yellow Re6ate Submillal Checklist). <br />Selec�t from the tollowing: <br />;, ❑ The conlraclor identilied downspouts or olher drainage Ilines lhat �vere connected to my sewer <br />� line (between my house and the inslalled device) and removed, or rerouted lhem. <br />�To my kno�vledge, my property has no downspouts or other dralnage connected to my sewer line <br />belween my house and the installed device). <br />� ❑ There are dovmspouls or other drainage lines connecled lo my sewer line (�etween my housc <br />and Ihe installed dovice). I understand thal leaving lhese connections creales a risk o( Ilooding <br />i and I accept thal risk. <br />� <br />Signature Dafe S 'L � _ <br />