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I <br /> � Backwater Prevention Device Rebate Program <br /> � � Rebate Application Form <br /> 1 ProperryOwnerName��,/O�Pd� l7//7rlC(il'� <br /> i . <br /> InstallationAddress: /7�S �(17� <br /> � City:�,�/�`G� State:�_Zip:;7 b01=i� <br /> ' MailingAddress(ifditferent): �/�� �2�� f�w <br /> ICity��l1/. �i� State:� Zip:QlS�.�� <br /> ' Emaifj�,/,)nG.rC' .�l�o� Phone:�� /.�T��O/ / <br /> � �� � �12 OD <br /> Total Cost to Instail Device {from contractor invoice): $ �1 / �+� <br /> i <br /> � Please verity Me following: � <br /> � I am the owner ot the property where the backwater prevention device was instalied. <br /> 1 <br /> � I worked witn the contractor to determine lhe location for the backwater prevenlion device and <br /> ' understand that lhe decision regarding the Iocation of lhe device was mine. <br /> I �] My contractor inslructed me how to access, inspect, and maintain the device. <br /> � � I understand thal I am responsible for maintaining lhe backwater prevenlion device and keeping <br /> , it in good working order, unless it is installed in the city right-oi-way. <br /> � � If I seli my property, I will make potential buyers aware of the backwater prevention device and <br /> � the need to inspect and maintain il on a regular basis. <br /> I � I am enclosing all�of ihe necessary paperwork(use the yellow Rebate Submitlal Checklist). <br /> � '. <br /> � Select from the following: <br /> � ❑ The contractor identified downspouts or olher drainage Ilines that wE:e connected to my sewer <br /> � line(beNueen 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 /> I (belween my house an 1 the installed device). <br /> ' ❑ There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the(nstalled device). I understand that leaving these connections creates a risk of tlooding <br /> and I accept that risk. <br /> Signatu Date <br /> I ___ - - - - - - -- - - - - — - _ _ - - - - -- �- - <br />