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Backwater Prevention Dev�ce R�abate Prograrr� <br />Rabate Applicati�s�? rorm <br />Property Owner Name: _� � ` 1� � I J V <br />Installalion Address: d�� � ��< >� <br />City: cQ�� IPi l�l _ State: W r� <br />Mailing Address (if diflerent): <br />Zip: � 7 )� � <br />Cily: _ State: _ Zip: <br />Email � Y' 1 �O �� �li �i � � C..�� Phone� (U���fO`t�"07�� — <br />Tofal Cost to Install Device (lrom contractorinvoice): 5� SGO �� <br />, <br />Please verify the followiny: <br />�i am the owner of Ihe property where the 6ack�vater prevention device was installed. <br />,[�] I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device vaas mine. <br />[� My contraclor instructed me how to access, inspecl, and maintain the device. <br />� I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the cily right-of-way. <br />� If I sell my property, I will make potential buyers aware o( the backw�ter prevention device and <br />the need to inspect and maintain it on a regular basis. <br />� I am enc�osing aIl of the necessary papenrrork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contraclor identified downspouls or other drainage Ilines that �vere wnnected to my sewer <br />line (between my house and lhe installed device) and removed, or rerouted lhem. <br />❑ To my kno�vledge, my property has no downspouts or olher drainage connected lo my sewer line <br />(between my house and lhe inslalled device). <br />f(� There are downspouts or olher drainage lines connected to my sewer line (between my house <br />�and the installed device). I understand that leaving these conneclions creates a risk oF flooding <br />and I accept ihat risk. <br />Signature DatP � �� � <br />