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Backwater Pr�vention Device Rebate Program <br />Rebate Application Form <br />PropertyOvmerName: �C7LZ�� U�DR=��rE <br />Installation Address: 3011� � ��" ST (�'ET <br />Ciry: G�I �' "TT St�.!e: W{� Zip:_ �18 ZD � <br />Mailing /lddress (il diNerent): <br />Ciry: <br />State: <br />Email: G.URNQfuPuE,@GMH?J_. LOPn Phone: (42y 45 3 0880 <br />Total Cost lo Inslall Device (/rom contractorinvoiceJ: $ 2Sp(, •�{-6 <br />�--- ---- -- Q� Fo (pa��,(} �rnpUvl-� a,..�r <br />Piease verify the following: {,t �a v�--- VT 54 i� <br />9 `�.c,� �. � <br />�J I am the ov✓ner oi the properiy tivhere Ihe backwaler pre�enlion device w�s ins[alled. � � <br />� I worked wilh the conlractor to delermine th^ location for Ihe backwaler prevention device and �-3-�� �`""�`��' <br />understand Ihal Ihe decision �egarding the localion of the device was mine. ?� �t— <br />�J M1y contraclor instrucled me how to access, inspecl, and maintain Ihe device. <br />�j I understand that I am respansible for iiiaintaining the backwater prevention device and keeping <br />il in good working order, unless il is inst211ed in ihe city right-ot-way. <br />(� If I sell rny property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain il on a regular basis. <br />� i am enclosiny all of the necessary paperwork (use the yellow Rebale Submittal Checklist). <br />Select from the following� <br />❑ The contractor identified downspouts or _�;ner drainage Ilines Ihal were connected to my sewer <br />line (be�ween my house and the installed device) anA removed, or rerouled Ihem. <br />[� To my knowledge, my property has no downspouls or olher drainage connected to my sewer line <br />(br.riveen my house and Ihe installed device). <br />❑ There aie downspouls or other drainage lines connected to my sewer line (be�ween my house <br />and lhe inslalled device). I understand lhal Ieaving these connecfions creales a risk of �looding <br />and I accepi that risk. <br />Signamre C' U��e- Date .3 � � ��Z��S <br />