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Backwater Prevention Device Rebate Program <br />Rebat� Application Form <br />�--- ------ -- -- <br />� Properh, OwrerName: Jl.t.�—I,� Y�w� <br />Instailation Address <br />City. �/P^'"� <br />! 64ailing Address (rl dil(erentJ: <br />/D I��'`'�/' <br />_State:/il/� Zip: g�� � <br />� City State Zip: <br />Email: �l� l?7�*/� �3 CiI �� L— -�o,�, Phone: (yZ� 30� ozF�s(z <br />Total Ccst to Install Device (/rom contr�ctor invoice): 5 <br />Plcase verify the tollowing: <br />� I am the ovmer of Ihe properfy v;hera the backwaler prevention device was installed. <br />�I �vcrked �vith the contractor to determine the location (or the backe�ater prevention device acd <br />understand that the decision regarding the location of the d�vir,e was mine. <br />/ <br />(/� IJIy corVactor instructed me ho�v to access, inspect, and maintain the device <br />�{%� I understand that I am responsible for maintaininc� iha back�r�af2r prevenfica device and k=_eping <br />it in good work,ing order, unless it is installed in the city nghto`-way. <br />ij%"� If I sell my property, I will make potential buyers aware of the baclnvater prevention device and <br />lhe need to inspect and maintain it on a regular ba ;is. <br />�J�j I am endosing all of the necassary papenvork (use the yellovi Rebate Submiltal Checklist) <br />SelectJrom the following: <br />The contractor idenOfied downspouts cr other drainagc Ilines Biat vrere conn�cted to my se�.aer <br />IPe (be4veen my house and the installed device) and remcved, or rerouted them. <br />�To my knowledge, my propeity has no downspouts or other drainage connected to rny sewer line <br />(between my house and lhe installed device). <br />��Therz are downspouts or o[her drainage lines connected to my set•+er line (between my house <br />and the installed device). I undersland that leavir.g lhese mnnections creates a risk of (looding <br />anri I acccot that nsk <br />Signafurc__ � �(�wL� <br />% <br />Date I/� y /�� <br />