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4Backwater Prevention Device Rebate Program <br />" Rebate Application Form <br />Property Owner Name: irk d ' f n e <br />Installation Address: 11911 �tjwt Si' <br />City: <br />fit) State: UjA Zip: <br />Mailing Address (if different): <br />City: <br />Email' <br />State: <br />Total Cost to Install Device (from contractor invoice): $ <br />Phone: ( <br />Please verity the following: <br />(� I am the owner of the property where the backwater prevention device was installed. <br />[XJ I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />[� My contractor instructed me how to access, inspect, and maintain the device. <br />UY I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />The contractor identified downspouts or other drainage (lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />(yb There are downspouts or other drainage lines connected to my sewer line (between my house <br />% and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />AV)r I Date <br />