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� Backwater Prevention Device Rebate Progra�m <br /> Rebate Appiication Form <br /> �--- <br /> Property Owner Name: �,1 e��1Ls� .0 BG9/IL:S <br /> Installation Address: I b OS �G (/=l�eQ�✓ /r]"�/E.� <br /> City: � v��/� State: V�'7 Zip:_ % �' r <br /> Mailing Address(ildiHerent): <br /> City: Stale: Zip: <br /> emai�: ' �Of.�A�O�lFO'F�9����• CAf1 Pnone:(�5) ,��O� '�773 <br /> Total Cost lo Install Device (from contractorinvoice): $ ��7 �� a! <br /> Please verify tha tollowing: <br /> �am the owner of the property where the backwater p�evention device was installed. <br /> �orked with the contraclor to determine the location for the backwater prevention device and <br /> understand that the decision iegarding ihe location of the device was mine. <br /> �My contractor instructed me how to access, inspect, and maintain the device. <br /> [.�j�l understand that I am responsible for maintaining Ihe backwater prevention device and keeping <br /> it in good wcrking order, unless it is installed in the city right-of-way. _ <br /> If I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> [�I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: • • • <br /> �he contractor identi(ied downspouts or other drainage Ilines that were connected to my sewer <br /> Iine(between my house and ihe installed device)and removed,or rerouted them. <br /> �my knowiedge, my property has no downspquls or other ra' age�connect�d to�y_sewer I�'� <br /> (belween my house and the installed device�'�y (#'l4UP' it��l �r•,•�� �v� <br /> ❑ There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Slgnafure Date �`� � Q�� <br /> /�17 C� A�( �0�1� �s <br /> �---- - --------- --- -- - --- - <br />