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Backwater Prevention Device Rebate Program <br />Rebate �4:pplication Form <br />Property Owner Name: �! �/ wrtY, J- I�.a-'m_�; <br />InstallationAddress: �i IJJa�Q.�-_ S-�-re-�''- <br />;.ity: 7f �•�• State: �_ Zip: �� 2,� ! <br />Mailing Address (il diNercnt): �� ��' �' ���`" �- s� <br />Cily: �° �-`� ��� State: 1� F� Zip: R��9�'c <br />Email: ��'� I-200 0� c�`-aa . Qp1�,_ Phone: �) a-8'o -� 9�3 <br />� <br />Total Cost to Inslall Device (lrom confractorinvoice): $ <br />Please veri(y the following: <br />[�I am the owner o( the propeAy where the backwater prevention device was installed. <br />�worked with the contractor to determine the location for the backwater prevenlion device and <br />understand that the decision regarding lhe location of the davice was mine. <br />[�My oontractor inslrucled me how to access, inspect, and maintain the device. <br />�nderstand that I am responsible for maintalning lhe backwater prevention device and keeping <br />il in good working order, unless it is installed in lhe city, righbo(-way. <br />[�] If I sell my property, I will make potential buyers aware of Ihe backwaler prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�am enclosing all of Ihe necessary paperwork (use the yellow Rebale Submiltal Checklist). <br />Select irom the following: <br />❑ The contraclor ide�tilied downspouls or other drainage Ilines that were connected to my sewer <br />line (betv✓een my house and the installed device) and removed, or rerouted them. <br />�o my knowledge, my property has no downspouls or other drainage connectod to my sewer Ime <br />(between my house :�nd Ihe inslalled device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the Inslalied device). I undersland that leaving these connr.ctio �s creates a risk o( (loodinc� <br />and I accept thal risk. <br />Signature �����` Dafc ��"2� I'�'° ( � <br />