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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: � roVz lsL1'Y6 <br />Installation Address: Z <br />City: <br />6UE/i'T <br />/D zz"0Sj <br />Stale: W+F% Zip:_ 48�� <br />Mailing Address (if different): <br />City: _ State: <br />Email: _ <br />Zip: <br />Phone: <br />Total Cost to Install Device (from contractor invoice): $ $ �j �1 O <br />Please verify the following: <br />Lam the owner of the property where the backwater prevention device was installed. <br />�I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />My contractor instructed me how to access, inspect, and maintain the device, N <br />1 understand that I am responsible for maintaining the backwater prevention device 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 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 lines that were connected to my sewer <br />line (between my house and the installed device) and removed. or rerouted them. <br />,KTo my knowledge, my property has no downspouts or other drainage connected to my sewer Ilne <br />(behveen my house and the installed device). <br />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 />Signatur �`—� Date1��/�/� <br />