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4Backwater Prevention Device Rebate Program <br />--rr Rebate Application Form <br />Property Owner Name:Oyc J��J )J? % r��, ✓`J <br />Installation Address: <br />City: <br />Mailing Address (if different): __—_.-._. -___._._- <br />City: _- Stale: <br />Email: <br />Total Cost to Install Device (from contractorinvoice): $ <br />Zip:—..-..--- -... <br />Phone: ( ) <br />Please verify the following: <br />(/ I am the owner of the properly where the backwater prevention device was installed. <br />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 />IE, My contractor instructed me how to access, inspect, and maintain the device. <br />[�I understand 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 />Q 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 />a I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklisl). <br />Select from the following: <br />�J The contractor identified downspouts or olher drainage Ilines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />[�f To my knowledge, my property has no downspouts or other drainage conneded to my sewer line <br />(between my house and the installed device). <br />J There are downspouts or other drainage lines connected to my sewer line (brtwoon my house <br />and the installed device). I understand that leaving these connedion cre;itus o nsk of flooding <br />and I accept that risk. <br />Signature— �f _ Date <br />