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_ _ _ ___ _ __ ___ l <br /> � Backwater Prevention Device Rebate Program <br /> Rebate A�+plication Form <br /> Property Owner Name: f � ' t ' ���' ' � .! : c <br /> Inslallation Address: � � � ` �-' :- <br /> ;: . <br /> City: : � � ' :�� State: 2ip: _ <br /> � . � r ; �f: . . ' 1 . . <br /> Mailing Address(it diNerent): � <br /> , <br /> City: � State:_ Zip: .. . _ � <br /> , � <br /> Email: � ' � Phone: ( ) � <br /> I Total Cost lo Ins�all Device(/rom contracfor invoice): $ ,1�q 3 .�� <br /> IPlease verify the tollowing: <br /> 0 I am lhe owner o(the property where lhe backwater prevention device was installed. <br /> i ❑ I worked with the contrador to determine the localion for the backwater prevention device and <br /> undersland ihal the decisiun reyarding the location of lhe device was mine. <br /> ❑ My contractor instructed rne how to access, inspect, and maintain the device. <br /> ! ❑ I undersland that I am responsible for maintaining the backwater prevention device and keeping <br /> i il in good viorking order, unless it is installed in the city right-of-way. <br /> i <br /> ❑ If I sell my property, I will make potential buyers aware o(the backwater prevention device and <br /> j the need lo inspect and maintain it on a regular basis. <br /> ❑ I am enclosing all of the necessary papenn�ork(use the yellow Rebale oubmillal Checklisl). <br /> � <br /> � Select from the following: <br /> ❑ The coNractor identified downspouls or other drainage Ilines lhat were connecteA to my sewer <br /> � line(between my house and ihe installed device) and removed, or rerouled them. <br /> ❑ To my knowledge, my property has no downspouls or oRier drainage connected to my se�.vPr line <br /> (belween my house and the installed device). <br /> ' ❑ There are downspouts or other drainage lines connecled lo my sewer line(behveen my house <br /> and the installed device). I understand Ihat leaving lhese conneclions creates a risk of 1looding <br /> , and I accepl�hat risk. <br /> Signature Date <br /> I <br />