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�,�}� Backwater Prevention Device Rebate Program <br /> �'��F,, Rebate Application Form <br /> ��--- <br /> Property Owner Name: d5 E L� ('I /7 /�C' l�i✓ <br /> Installation Address: ���t 4` ��E 7-f7 D iPt� �l�� <br /> c�iy: �V�/; E r r State: _��Zip: 9 �d O � <br /> tvtailing Address(ildiHerentJ: <br /> City: State: _Zip:__ <br /> [mail: Phone: ( ) <br /> Tolal Cosl to Inslall Device ((rom confraclorinvoice): S <br /> � <br /> Please verify the following: <br /> �'I am the owner of the property where the backwaler prevention device was instailed. <br /> � I �vorked with the contractor lo determine the location for lhe backwaler prevention device and <br /> understand Uial lhe decision regarding lhe location of ihe device was mine. <br /> �f My contraclor instructed me ho�v lo access, inspect, and maintain the device. <br /> �' I understand lhat I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in lhe city righl•of•way. <br /> �" If I sell my property, I will make potential buyers a�vare o(the backwater prevenlion device and <br /> the need to inspect and maintain it on a regular basis. <br /> ,�I am enclosing all of Ihe necessary papeRvork (use the yellow Rebate Submittal Check�ist). <br /> Select from the following: <br /> ❑ The contractor idenlified downspouts or oUier drainaqe Ilines thal acre connecicd lo my sewer <br /> linc(between my house and the installed device)and removed, or rerouled them. <br /> �To my knowledge, i�y property has no downspouls or olher drainage connected to my sewer line <br /> (between my house and the installed device). <br /> J There ere downspouls or other drainege lines connected to my sewer line(beRveen my house <br /> and ihe Installed devlce�.I unAerstand that Ieaving Ihese connections crexles a risk of 11a�iing <br /> and I accept that risk <br /> Signal�re����_��-a-m.J Date � —1�- .�(�l� <br /> � <br />