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Backwater Prevention Device Rebate P�•ogram <br />Rebate Applicatian Form <br />PropertyOwnerName: kj(1..�.1� �• �vIIU.�- � mWi��� �K� <br />Installalion Address: 3 I � 3 P>� S7 <br />Cily: �V �L'�Tf- State: W % Zip:—J�!�) ___ <br />Nlailing Address (if di(ferent): ��''��G <br />City: �('E�F%'m Slate: (�/-F� Zip: J�Z �I <br />Email: u�d — bI �' Y'I ��2%�0 •� M phone: (gC�) a-� �-�i`� <br />Total Cost to Insall Device (from contractor invoice): S <br />Please verify the following: <br />�I am the owner of the �roperty where the back�valer prevention device was installed. <br />I worked with the contractor to dotermine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />� My contractor instructed me how to access, inspect, and maintain the device. <br />�I undersland that I am responsible for mainlaining Ihe backwater prevention device and keeping <br />it ir� good working 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 enc!osing all of the necessary papen,vork (use the yellow Rebate SubmiUal Checklist). <br />Select from the following: <br />❑ The conlractor ideniified downspouls or other drainage Ilirzs that �vere connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />�To rny knowledge, my property has no downspouts or other urainage connecled to my sewer line <br />(between my house and the inslalled device). <br />❑ There are downspouts or other drainage lines connected fo my sewer line (between my housa <br />and the installed device). I understand lhat leaving these connections creates a risk of (looding <br />and I accepl Ihat risk. <br />Slgnaturevli.e,G%�=�.� /`. /���G'/� Date Z Z. -� /ti"' �s <br />