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� <br />Backwater Prevention Device Rebate Program <br />Rebate Appiication Form <br />Property Owner Name: 1��,u / fac.rPer <br />Installation Addr�ss: � <br />City:�vere.P-�' State:l„i� Zip: y�7.�1 <br />Mailing Address (i/diHerent): <br />Cily: <br />Email: <br />Siate: <br />Phone:(N�) Z�'3�/l.f <br />Total Cost to Install Device (from contractor invoice): S� feG .r� <br />Please verify the following: <br />� I am the owner of the property where the backwater prevention device v�as installed. <br />� i worked with the conVactor to determine the location for the backwater prevention device and <br />understand that ihe decision regarding the location of the device was mine. <br />� My contractor instructed me how to access, inspect, and maintain the device. <br />I� I understand that I am responsible for maintaining the backwater prevention device and keepirg <br />r it in good working order, unless it is installed in the city righl-o!-way. <br />[� I( 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�i I am enclosing all o( the necessary papenvork (use the yellow Rebate Submittal Checklistl. <br />T <br />Seiect from the foilowing: <br />❑ The conlractor identified dovmspouts or other drainage Ilines that were connected to my sewer <br />line (beriveen my house and the installed device) and removed, or rerouted them. <br />❑ To my knuwledge, my property has no downspouts or other drainage connected lo my sewer line <br />(belwPen my house and lhe inslalled device). <br />I�' There are downspouts or other drainage lines cennected lo my sewer line (between my house <br />Y� and the installed device). I understand that leaving these conneclions creates a risk of flooding <br />and I accept that risk. <br />/ <br />g �� � Date __,���_ <br />Si nature <br />