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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: � <br /> Installation Address: �L�o_� A1,0�-�c �J_G, <br /> City. ���I�i I T State� L(.� ___Zip:�Zb I __ <br /> Mailing Address(if dit(erent): <br /> City: State: %'ip: <br /> Email: `J�wSF.s�l�'��iM/FI L. C'ivU Phone: (3�r-3�y08 1 <br /> Total Cost to Install Device (trom contrector invoice): $�,�� � i <br /> r <br /> Please verify the following: <br /> �I am the owner of the property where the backwater prevention device was inslal!ed. <br /> �I �vorked wilh the contraclor to determine the location fur the backwater prevention device and <br /> ' understand lhat lhe decision regarding the location of lhe device was mine. <br /> (�My conlraclor instructed me how lo access, inspect, and maintain the device. <br /> �I understand that I am responsible for maintaining lhe backwater prevention device and keeping <br /> it in good working order, unless il is installed in the cily right-of-way. <br /> �If I sell my properly, I will make potential buyers aware oi the backwater prevention de�ice and <br /> the need lo inspecl and mainlain i� on a regular basis. <br /> �I am enclosing all of lhe necessary paperwork(use the yellow Rebale Submil�al Checklisl). <br /> Select from the following: <br /> ❑ The conlractor idenli(ied downspouts or olher drainage Ilines lhat were connected to my sewcr <br /> line(betaeen my house and lhe installed device)and removed, or rerauted ther,�. <br /> , To my knowledge, my property has no downspouts or other.drainage connecled to my sewer line <br /> ` (belween my house and the installed device). <br /> ❑ There are downspouls or olher drainage lines ccnnecled to my sewer line (between my house <br /> and the installed device). I understand thal leavinc� these conneclions creates a risk of flooding <br /> and 1 accept that risk. <br /> , <br /> � <br /> Signature ' Date �f � l.� <br />