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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property0wnerName: .J Anne- _au��Il <br /> Installation Address: a�J�� C��9 � `J9+ <br /> Ciry: �V�Qw^Q..�-�' State: I��_Zip: q�20I _ � <br /> Mailing Address (iI dil/erent): <br /> City: Stale: Zip: <br /> Email: ���� g � �yG1 hQO. CdYYI Phone: (�I� ,314 -5 8 7/ <br /> /' 3�-- <br /> Total Cost lo Install Device ((rorn contraclorinvoice): $ '�-��'7- <br /> Please verify the following: <br /> �am the ovrner of the property where lhe backwater prevention device was installed. <br /> �worked wilh the contrac�or to determine the location for the backwaler prevention device and <br /> understan�j that the decision regarding the location of the device was mine. <br /> [�My contraclor instructed 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 insi�lled �n the city right-of-way. <br /> �I sell my property, I will make potenlial buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on � regular basis. <br /> �am enclosing all of the necessary paperwork(use Ihe yellow Rebate Submittal Checklist). <br /> Selec`.fiom the following: <br /> ��The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> line (beM�een my house and the installed device) and removed, or rerouted'them. <br /> �o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> There are dowr.spouts or other drainage lines connected to my sewer line (between my house <br /> � and the installeo devir.e). I undersland lhal leaving these connecllons creates a rlsk of Oooding <br /> and I accept that risk. <br /> Signatur k _Date 1� <br />