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Backwater Prevention Devic� Rebate Program <br />Rebaie Application Form <br />Properfy Owner <br />Installalioi ddross: �fGTL/ / /O—' <br />Cily: -��.e(� _ State: W� <br />� � <br />,8a��, <br />P� ili ddross (i(dIl/erentJ: �rEi<1 J' � � ' p -- <br />���lGUCGC�P�(> Slale: �� Zip: G v•Z7,� <br />Email: Y 5 r,�li�1Cl��Q�py�� Phone: �� 4� "� � <br />Total Cost to Install Devlce (Irom contractor involce): 5 �� �� -��� <br />Ploase verify the foliowing: <br />�! am the owner of Ihe property where the backwaler prevenfion device was instalied. <br />❑ I�•rorked wllh the conlractor to determine the locatlon for the backwaler prevention device and <br />undersland thet tiie decision regarding Ihe location of the device was mine. <br />❑ My conlraclor inslructod me how to access, inspact, and malntaln Ihe device. <br />� I undersland that 1 am rosponsible for mainlaining the backwater pr�ventlon devlce and keeping <br />(t In good working order, unless it is inslailod In the city right-of-way. <br />� If I sell my property, I will make potenlial buyers aware of ihe backwater preventlon device and <br />the need to Inspect and mainlain il on a regular basis. <br />� I am enclosing all of the necessary papeisvork (use the yellow Rebale Subm(ttal Checklist). <br />Solact from the following: <br />❑ The conlraclor idenlified downspouls or other dralnage Ilines ihat woro connecled to my sewer <br />line (botween my houso and the I�stalled device) and removed, o� rerouted lhem. <br />�To my knowledge, my propeAy has no downspouls or other drainaye connected to my sewer Iine <br />(botween my house and the installed device). <br />n There are downspouts or olher dralnage lines cannected lo my sower linc (behvoen my house <br />and the insialled device). I undersland Ihat leaving ihese conneclions creales a risk of Oooding <br />and I accept that rlsk. <br />��-��-�� <br />