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4Backwater Prevention Device Rebatq Program <br />� Rebate Application Form <br />Property Owner Name:'—��>ea1p� <br />Installation Address:` <br />City: v'EyE! I Stater Zip_ <br />Mailing Address (if different): <br />City:= is'�� State:_ Zi � ©( , <br />Ema'ct� X��\ d ,"`q��' Phone: (-,kZ <br />Total Cost to Install Device (from contractor invoiceC$ _ <br />Please verify the following: <br />the owner of the property where the backwater prevention device was installed. <br />di5j—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 was mine. <br />,E,PAy contractor instructed, ie how to access, inspect, and maintain the device. <br />fj'i-onderstand that I am responsible for maintaining the backwater prevention device and keeping <br />it in 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 />iite need to inspect and maintain it on a regular basis. <br />P—ram enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select fl om the following: <br />The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (between my house and the Installed device) and removed, or rerouted them. <br />4�]`To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Si refute <br />g --- Date -� /� <br />