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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: M 1 $ <br />Installation Address: I, \ <br />City: R V f 4{ 4 State: <br />Mailing Address (if different): <br />City: <br />State: <br />i ern Scars <br />Zip: 9 � a 0 1 <br />Zip: <br />Email: J3 oa a run L ku i vvvrti i 1 - C U Phone: (a.0)g C4i0 S - o`) I <br />Total Cost to Install Device (from contractor invoice): $ &P L)3 (n D <br />Please verify the following: <br />I am the owner of the property where the backwater prevention device was installed. <br />1 worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the loi:alion of the device was mine. <br />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 />in good working order, unless it is installed in the city right-of-way. <br />1A.7,�� 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 />S� am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from 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 />(i�]' To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />" �s (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 />Signature jrdtj Date <br />