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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: —�� C� t,i �-1 � S\ � l 9 <br />Inslallation Address: <br />t.�l� <br />City: � -- Stale: �� Zip: � �S �� � <br />Mailing Address (il diNerentJ: <br />City: State: ��p: <br />�� n 1 1 / <br />Email..J�ti �� ��=zrr,�+dc� C�tT�--._Phon� ) �2)� � U�7 �/ <br />Total Cosl to Inslall Device (1rom contrac[orinvoice): S_� Sa'•� <br />Ple��se verify the following: <br />�I am the owner o( lhe property where the backwater prevention device was installed. <br />[� I worked wilh the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />� My contraclor inslrucled me how to access, inspecl, and maintain ihe device. <br />� I undeistand thal I am responsible for maintaining the back�vater prevention device and keeping <br />il in good working order, unless it is installed in lhe ciry right-of-way. <br />� If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need lo inspecl and mainlain it on a regular basis. <br />�' I am enclosin� all of Ihe necessary papenvork (use lhe yeliow Rebale Submitlal Checklist). <br />Select from the followfng: <br />❑ The conUaclor idenli(ied downspouls or other drainage Ilines lhal were connected lo my sewer <br />line (between my house and lhe installed device) and removed, or rerouted them. <br />[] To my knowledge, my property has no downspouts or olher drainage connected to my sewer line <br />(belween my house and the installed device). <br />[C]� There are downspouls or other drainage lines connected to my sewer line (behveen my house <br />and the installed device). I understand that leaving lhese connections creates a risk of flooding <br />and I accepl lhat risk. <br />Slgnah�l� � Date ��e — (S <br />