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i <br /> �}l• Backwater Prevention Device Rebate Program <br /> , �i��,.,. Rebate Application Form <br /> i `_>._.. <br /> I <br /> Property O�vner Name: DN Gi .l� J )Kd �i�'� __ <br /> Installation Address: � - /./'�— <br /> .- <br /> I <br /> City:���_State:�Zip:�7��� / <br /> i Mailing Address(ildifleienf): <br /> I <br /> i City: State: 2ip: <br /> iEmail: Phone: ( ) <br /> Total Cost to Install Device(Irom confractorinvolce):$���•�� <br /> � Please verify the following: <br /> �i � I am Ihe ownor of lhe property where the backwaler prevention device was installed. <br /> � I worked wilh the coniractor to determine the IocaUon tor the backwater prevention device and <br /> understand lhat the decision regarding the localion of the device was mine. <br /> � � My contractor instructed me how.to access,inspect, and maintain the device. <br /> i [V] I.understand that I am responsible for mainlaining the backwate�-ptevention device and keeping <br /> it in good working order, unless it is inslalled in the city righl-of-v�ay. <br /> � If I sell my property, I will make polential huyers aware of the backwater prevention device and <br /> � the need to inspect and maintain it on a regular basis. <br /> �I arn.enclosing ail of lhe necessary papenvork(use Ihe yellow Rebate Submitlal Checklist). <br /> ISelect from the following: <br /> I �] The contractor idenlified downspouts or other drainage Ilines lhat wero connected lo my sewer <br /> �i line(between my house and the installed device)and removed,or rerouled them. <br /> ❑ To my knowledge, my property has no downspouls or olher drainage connected to my sewer line <br /> ' (between my house and the instalied tlevice). <br /> � There are downspouts or other drainage lines connecled to my sewer line(bclween my house <br /> �, and the inslalled device). I undersland ihat leaving lhese connections creates a risk ot flooding <br /> I and I accept that risk. <br /> � <br /> ' ' Date � ���� ` � <br /> Signature <br /> I <br /> I <br /> ,i <br />