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..__—__f ____� ____^ - �� -- ---, <br /> Backwater Prevention Device Rebate Program <br /> � Rebate Application Form <br /> Praperty Owner Name: 1���� . � \ �1�"'""'U �'✓�� � L�� �l � <br /> Installalion Address:._�� �� ��4'"�r <br /> City: �' State: l�^�r— Zip: _G`��'�7 <br /> futailing Address (il differentJ: <br /> Cily:__ State: Zip: <br /> Email: Phone: ( )�'� ��Q�� <br /> Total Cosl to Install Device (from contractor invoice): S o� �131 .$ e � <br /> Please verify the following: <br /> 7� I am lhe owner of lhe property where fhe backv✓ater prevention device was installed. <br /> �worlced wilh the contractor to determine the localion (or the backwater prevention device and <br /> undersland that lhe decision regarding thP location of the device was mine. <br /> [�My contraclor inslructed me ho�v to access, inspect, and maintain the device. <br /> �understand lhal I am responsible for maintaining the backvdater prevention device and keeping <br /> it in good working order, unless it is inslalled in the ciry right-of-way. <br /> �If I sell my properly, I will make potential buyers aware of lhe backwater prevention device and <br /> [�he need to inspect and maintain it on a regular basis. <br /> am enclosing all o(the necessary paperwork (use the yellow Rebale Su6mitlal Checklist). <br /> Select from the following: <br /> ❑ The conlrac�or idenlified downspouts or olher drainage Ilines Ihal were connected to my sewer <br /> line(between my house and the installed device) and removed, or rerouted them. <br /> dTo my knowledge, my property has no dovdnspouts or other drainage connected to my se�ver line <br /> (belween rny house and Itie installed device). <br /> ❑ There are downspnuts or other drainage lines connected to my sewer line (6etween my house <br /> and the inslalled device). I understand that leaving these connections creates a risk of flooding <br /> and I accept lhat risk. <br /> /r\ � � ( �>i <br /> �� � Q `—C 1 <br /> Signature �'r-�—/`- � Date J <br />