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1 <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Form �� <br /> Property O�vner Name'_,f��� Pav,l�/S_P_f11v <br /> Installation Address:��f��[I�Q(l�__�_�- <br /> Gty -��f��'� State. Whl _. P: °��� . . <br /> Mailing Address{ildif/erenQ: _�i � <br /> City: State Zip. <br /> EmaiC QO�NfA1�1�1tS1L�LL1�. �� _ Phone: (LI )308 • "11 (sa1 <br /> Total Cost to Install Device ((rom contraclor invoice): S ��� � <br /> Please verify the following: <br /> [.t� I am the owner of the properiy v+here the backwater p�evention device was installed. <br /> [X I worked�ti�ith the contractor to determine the location tor the backwater prevenlion device and <br /> understand lhal the decision regarding the location o'the device was mine. <br /> � My contractor inslructed me how to access,�inspecl, and maintain the device. <br /> [Jj I understand lhat I am responsible for maintaining lhe backwaler prevention device and keeping <br /> it in good�vorking order, unless it is inslalled in ihe city righl-o6way. I <br /> [��It i sell my property, I will make potential buyers av.�are of the backwater prevention device and <br /> the need lo inspect and mainlain il on a regular basis. <br /> dI am enclosing all of Ihe necessary papen��ork (use the yellow Rebate Submitlal Cheoklisf). <br /> Select from the fal�a::•:ng: ' <br /> ❑ The contraclor identified downspouts or other drainage Ilines that�vere connecled to my sewer <br /> line(behveen�my house a�nd 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 /> (betwcen my house and lhe instailed device). <br /> ❑ There are downspouls or other drainage lines connected to my sewer line (behveen my house <br /> and Ihe ins�alled device). I understand lhat leaving these connections creates a risk af(looding <br /> and I accept lhal risk. <br /> Signature � Date � <br /> s . <br />