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� <br />� <br />Backwater Prevention Device Rebat� Program <br />Rebate Application Form <br />Property Owner Name: �n � i�� �""e ��e�'� I <br />Installation Address: � 5 d � ��� � <br />Ci 1J� P� State: �/�i� Zip: �� 2D � <br />ry� <br />Mafling Address (if di� erant): _� , Y� <br />City:� ` State:�.,_.Zip ..-�/ �.� . <br />� � <br />Email: Y' �7 f CG. cn��� �.Mn /�C�ILPhone:('tZ����(}— G(nLt'�i <br />Total Cost to Instail Device (from contractor invoice): S 22''�i "j '�� �71� � <br />please verify the following: <br />�Jj I am the owner of the property where ihe backwater prevenlion device was installed. <br />7� <br />�1 worked with the conlractor to determine lhe location for the backwater prevenlion device and <br />understand that ihe decision regarding the location of the device was mine. <br />�] My contractor Instructed me how to access, inspecl, and maintain the device. <br />� I undersland thal I am responsible for mainteining the backwater preve�Gon,device and keepino <br />� it In good working order, unless it is installed in the city right-oi•way. �-' •••� <br />+�5. <br />�ii It I sell my property, I will make potential buyers awaro of the backwater.prevention device ane' <br />�C ihe need to insped and mafntain H on a regular basis. <br />� I am enctosing all oi the necessary paperwork (use lhe yellow Rebate Submittal Checklist). <br />�.�le,ct ro_m the FoilQw ng�_ __. .- --- — <br />-.. __ .. <br />�[,�J The contractor identified downspouls or other drainage Ilines that were connected to my sewer <br />f` line (between my house and the installed device) and removed, or rerouted them. <br />_T"(y To my knowledge, my properry has no downspouls or other drainage connecled to my sewer line <br />tT (between my house and the instelled devlce). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the instalied device). I understand Ihat leaving these connections creates a risk of flooding <br />and I accept lhat nsk. <br />' <br />J� Siqnaturu <br />' ` Date <br />