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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ovmer �Jam <br />Installation Address: <br />City: � ve f� State: _/iS�� Zip: C] `Q20� 22L�1 <br />�4ailing Address (i(di(ferent): <br />City: <br />State: <br />Email: jp„��{G� (����3�_— Phone: � =�L2 �7 f �– <br />Total Cost to Install Device (lrom contraclor invoice): 5 _ <br />Flease verify the following: <br />� I am.the o�vner of the property where lhe backwater p�evention device was installed. <br />❑ I worked with the contrector to determine the location for the backwater prevention device and <br />undersland lhat thc decision regarding the localion of the device was mine. <br />❑ My conlraclor instrucied me how to access, inspect, and mainlain the device. <br />❑ I understand thai I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, uniess il is installed in the city right-oi-way. <br />❑ I( I sell my property, I will make potential buyers aware of the backvdaler prevention device and <br />the need'to inspect and maintain it on a regular basis. <br />❑ I am enclosing all of Oie necessary paperevork (use thz yellow Rebate Submillal Checklisl). <br />Select from lhe following: <br />i] The conlractor identi(ied downspouls or other drainage Ilines �hat were connecled lo my sewer <br />Iine (between my house and ihe installed device) and rernoved, or rerouled them. <br />L1 To my knowledye, my property has no downspouts or olher drainage connected to my sewer line <br />(belween my f�ouse and lhe installed device). <br />❑ There are tlownspouts or other drainage lines connected to my sewer line (behveen my house <br />and the installed device). 1 understand that leaving these connections creates a risk of (looding <br />and I accept that risk. <br />Signalure <br />1 Date J-zn - 1 s <br />