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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Nan <br />Insta�lallon Address: <br />c�ry: F�r��ei�- Slale: W/� z�P: °Igzo � <br />Mailing Address (i(diNerenlJ: � S�IO� SC 3Ott' j��..G. � ��V <br />Cily: I�i2_��gY�w.(. Slate: W� Zip: �g�U� <br />EmaIL '��ovt�u�—l^: 1�1v�iti-4iohhon�aa•Cnn,_Phone:(�t.) uL8•�f3bU <br />Tolal Cost to Install Device (lrom contraclor invoice): 5 Z S Od <br />Please verlfy the following: <br />j� yam the owner of Ihe property where Ihe backwaler prevenlion device �vas installed. <br />[ I worked wilh Ihe contractor to deler,rine the tocation for lhe backwater prevenlion de�lce and <br />[�Mdersland Ihat the decision reaanJing Ihe location o! the device was mine. <br />y contractor Ins:rucled me how ;o access, inspect, and maintaln lhe device. <br />� undersland thal I am responsiblii tor malnlaining lhe backwater prevenlion de�ice and keeping <br />it in good working order, unless it is inslalled In the city right�of•way. <br />�1 I sell my property, I will make pot: ntial buyers aware of the backtvater prevenlion device and <br />�e need to inspecl and maintaln it on a regular basls. <br />am enclosing all oF Ihe necessary pepenvork (use lhe yelloai Rebate Submittal Checklisq. <br />Selecl trom Ihe following: <br />❑ The conlraclor ldenUfied downspouls or other drainage Ilines thal were connected to my sewer <br />line (bohveen my house and Ihe installed device) and removed, or rerouled lhem <br />❑ To my knowledge, my property has no do�vnspouts or olher drainage conneded to my sewer line <br />(beRveen my housc and Ihe inslalleA devlce). <br />❑ There are downspouls or olher dramage lines connecled to my sewer hne (belween my house <br />and Ihe installed device). I understand Ihal leaving Ihese connections creales � risk of floading <br />and I accepl lhat risk. <br />Signaturc'�.����`L��� ___� �_Dafe�/ /�� �� <br />� <br />� <br />