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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ocmer Name. -� ��1� U <br />I�sla!lation Address' � S� � � <br />���,, F t>'�1 K �. r i <br />�•:taiiir,g Address (il dil;e�ent): <br />City <br />1 1�� <br />State. V1' � <br />Slate <br />� �' s�-�� <br />s� <br />Zip: �O�%� � <br />Emzil: Phone. (� <br />Tc t�i Cost to Install Device ((rom corrtractor im�oico): S Z474 • �� <br />Please verify the following: <br />� I am the oemer of the property where the backv�ater prevention device �vas installed. <br />fV� i worked with the conlractor to determine lhz localion for the backvdater prevention device and <br />%�' understand lhal the decision regarding the location o` the device was mine. <br />:1 <br />1'1 <br />My coniractor instructed me how to access, inspect, and maintain the device. <br />I understand that I am responsible for maintaining the hackwater prevention device and keeping <br />it in good working order, unless it is installed in tiie city right-of-vday. <br />j�J If I sell my properly, I will make potential buyers aware of the bsrk�valer prevention device and <br />the need lo inspect and mainlain d on a regular basis. <br />�( I am enclosing all of the necessary paperv��ork (use lhe yeUw� Rebate Submittal Check�ist). <br />�v <br />Select from the following: <br />j�'J ihe contract: r identified downspouts or other drainage Ilmes that were connected b my sewer <br />iine (between my house and ihe installed device) and removxl, or rerouted Iham <br />j}� To my knowledge, my property has no downspouls oi olher drainage connecled lo my se�ver line <br />�� (between my house and the installr.d device). <br />(� There are downspouls or other drainage lines connecled lo my sewer line (belween my house <br />2nd the installed device). I undersland lhal leaving these conneclions creates a risk o( flooding <br />and I accept that risk <br />Signature�������'i. ✓"`���'— Date Zl�� -�l� <br />