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Backwater Prevention Device Rebate Program <br /> Rebate Applicatipn Form <br /> I PropertyOvmerName: ����`n"1-- N""`t'"¢S-� <br /> Installalion Address:__� -�? �) 4� S� S � <br /> � �� / <br /> I City: Isd/k'G�"' State' w h- Zip. S'�7.� � -_— <br /> Mailing Address (i(dilferent): !1 �S S / k ���_�-� � '� __ __ <br /> II / <br /> � Cily: �✓I�.� , u.� State: I../I.L- Zip:__P�" C� _. i <br /> �:�•i� � d�Gtu�„�� a 6Z.w�F'�...:� /bm Phone: (�i �'z. (��-9 <br /> Email: � �— <br /> Total Cost to Install Device (from confracta invoice): 5_�tS�. �/ ____. <br /> Please verify the following: <br /> �I am the or:ner o( lhe property c�here the backwater prevention device was installed <br /> [�,�I r�orked vnth the contracror lo delermine the localion for lhe backv�aler prevenlion device and <br /> understand that lhe decision regarding the location of the device was mine. <br /> [�My conlractor instructed me how to access, inspect, and maintain the device. <br /> / <br /> � I understand lhat I am responsible (or maintaining ihe backv✓aler prevention device and k �epiny <br /> il in goad working order, unless ii is installed in the ciry right-of-way. <br /> f�'1 If I sell my property, I will make polential buyers aware of Ihe backwater preve�tion device and <br /> the need to inspect and maintain it on a regular basis. <br /> '✓� I am enclosing all of the necessary papenvork (use the yellow Rebate Submittal Checklisl). <br /> Select from the fallowing: <br /> [j The conlractor identified downspouts or other drainage Ilines that were connecled lo my sewer <br /> line (helween my house and lhe installad device) and removed, or rerouted them. <br /> [� To my knowledge, my property has no downspouls or olher drainage connecled lo Rny se�ver line <br /> (between my house and fhe installed device). <br /> [� There are doe✓nspouls or other drainage lines conner,led lo my sewer line (behr�een my house <br /> and the installed device). I understand lhat leaving these connections creates a nsk of tlooding <br /> and I accept lhat risk. <br /> � <br /> Signature � �� Date � ��/�� <br />