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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: Gf32 � C/.�v r o _ <br />Inslallation Address: / Yia �� �� S •% <br />City: L"Gi'/r'L�J7� State: Wfl Zip: 9J,=.7d,1 <br />Mailing Address (i1 dillerenf): �n • � Jx �iS.��' <br />City: eY�'tPr'1f State: 1-��. zip: 9�',� /? <br />Email: Phone: (� 1.5.�' -- 9 �f�3' <br />Tolal Cost lo Install Device (fram contractorirtvoice): $ 7�Ct `l "� <br />Please verify :he f�llowfng: <br />{�I am the ovmer of ihe property where tiie backwater prevention device was installed. <br />0' I worked with the contractor to determine the location tor ihe backwater prevenlion device and <br />understand ihat Ihe decision regarding lhe localion of Ihe de�•ice was mine. <br />[� My contractor ins6�:ded me how to access, inspect, and maintain the device. <br />� I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is inslalled in the city right-of-way. <br />B" If I sell my property, I will meke poteMiai buyers aware of Ihe backwater prevention device and <br />the need to inspecl and maintain it on a regular basis. <br />[� I am enclosiny all of Ihe necessary paperwork (use the yellow Rehate Submitlal Checklist). <br />Select irom thc following: <br />❑ The contrnclor idenlified downspouts or other drainage Ilines that were connected lo my sewer <br />line (belween my house and the Installed device) and removed, or reroutcd them. <br />�To my knowledge, my property has no dovmspouls or other drainat�e connected to my sewer line <br />(hetween my house and tfxm installed device). <br />j] There are downspouls or other draina�e lines connecled to my sewer line (belween my house <br />and the installed device). I undersland that leaving these conneclions creates a risk of Ilooding <br />and I accept lhat risk. <br />// <br />Signafure —�C -�M�� Oate � � � �•S <br />