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�,�},.,r Backwater Prevention Device Rebate Program <br />^�� Rebate Application Form <br />M�Cv5 itti/ <br />��/ <br />- � � <br />Prcper,y O�vner Name ���' IG�`!� �1 f/ �-L[��,�_��� � � <br />Installation Fldtlress�. �t�� �h �� — � <br />n L �^`T� <br />Cily C��.(rP�'i�{' State: ���1 Zip.� ' <br />i <br />i�laihng Address (ifdiKerent): <br />City: _ State. <br />Email: <br />Total Cos� to Install Device (horn ccntractorirvoice) S <br />� <br />Phone �Zf� Zf'•�>- 13� t <br />Please verify the following: <br />�) I arn the owner of the proper;/ where ihe backwater prevention device was instatled. <br />�"I I�vorked tvilh the con(ractorto de[ermine the location for the back�vater prevention device and <br />�T understanc tl�at the decis�on regarding the locafion of lhe device was mine. <br />,� Ny contractor instruct�d me how lo access, inspect, and maintain Ihe dzvice. <br />-\ <br />�i I ur.dersland that I am responsible tor main!aining the backa�ater prevention device and keeping <br />'` it in good v�crking order, unless it is installed in the aty right-of-�vay. <br />�j If I sell my property, I tivill make potential buyers aware o( Ihe bachwater prevention device and <br />the need to inspect ano maintain it on a regular basis. <br />(� I am enclosing all of the necessary pa, ework (use ihe yellow Rebate Submiltal ChecklisD <br />Se�ect from lhe following: <br />1}`1 The contrac;or identi(ied downspo�ts or niher drainage Ilines thal were connected lo my sewer <br />line (bet�ti�een my house and the installed devicc) and removed, or rcrouled them. <br />IC.) To my knoedledge, my property has no downspouts or other drainage connected lo my sewer line <br />�� (between my house and lhe installed device). <br />�There are dovmspouts or other drainage lines connected to my sewer line (betwe.en my house <br />and the installed device). I undersfand �hat leaving lhese connections creates a risk o( floodina <br />and I accept lhat risk. <br />Signature \l���� � Daro �— Iv- �� <br />� <br />� <br />