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- -- -.---------- --- _-----��. <br />Backwater Prevention Device Rebate Program <br />E,, Rebate Application Form <br />Property Owner Name: i\ � i� ���. y V 1�'.���°S <br />Inslallation Address: �a � I� I�1 S� <br />City: � I\ 'E�_ Slale: �_ Zip: <br />Mailing Address (il dilferent): ���Z� ��Y c� �� �(�� �.f/ <br />Ciry: ��11� Il/�� state: �� Zip:�'�D ZG� <br />Emaii: �F_1 �`i��l L�I��V u �IL.S .�Cj/yj phone:.�j)G�a �—!� <br />Total Cost to Install Device (/rom contractorinvoiceJ: $ ��U�• � __ <br />Please verify the following: <br />�I am lhe owner of the property where the backwater prevention device was installed. <br />'�_ I evorked with the contractor to determine the Iocation For the backwater prevention device and <br />understand that the decision regarding lhe location oi ihe device was mine. <br />� My contractor insiructed me how to access, inspect, and maintain the device. <br />� I understand that I am responsible tor maintaining the hackwater prevenlion device and !ceeping <br />it in �ood working order, unless it is installed in the city righl-of-way. <br />�j If I sell my property I will make potential buyers aware of ihe 6ackwater preven;ion device and <br />� the need to inspect and maintain it on a regular basis. <br />[� I am enclosiny all of the necessary paperwork (use lhe yellow Rebale Submittal Checklisl). <br />Select from the following: <br />.� The contraclor idenlified downspouts or other drainage Ilines that wero connecled to my sewer <br />line (hetv�e�n my house and the installed device) and removed, or rerouted them. <br />(�"fo nry knowledge, my property has no dowr�spouts or other drainage connecled to my sewer line <br />(belwedn my house and the installed device). <br />❑ There are downspouts or other drainage lines cennected lo rny sewer line (between my house <br />and the inslalled device). I undersland lhat leaving lhese wnnections creates a risk of (looding <br />Date � <br />