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Backwater Prevention Device Rebate Program <br />0�w <br />Rebate Application Form <br />Property Owner Name: i� r �✓� L <br />Installation Address: Z ! O c7-- <br />City: %tie�� State: Llli Zip: 9<,?261_ <br />Mailing Address (it different): [ o, (&'� K-Se") <br />City: �yr c *,- State: L li4- Zip: q a'04 <br />Email: XZ <41/-I to_ e 0okl& s r- • ^Jc �' Phone: V;1 T �'Z 3 —10C/ q <br />Total Cost to Install Device (from contractor invoice): 5 4 c4 '�K <br />Please verify the following: <br />[r I am the owner of the property where the backwater prevention device was installed. <br />worked with the :.ontractor to determine the location for the backwater prevention device and <br />understand that the d cision regarding the location of the device was mine. <br />❑'My contractor instructed me how to access, inspect, and maintain the device. <br />❑"'(understand that I am responsible for maintaining the backwater prevention devic^ and keeping <br />It in good working order, unless it is installed in the city right-of-way. <br />❑" If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />i <br />am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Mines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />["To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />n There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature Date i Ors <br />