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� _ <br /> ; Backwater Prevention Device Rebate Program <br /> ' � Rebate Application Form <br /> I <br /> ' Property Owner Name: �'C�V���'n��� <br /> � Installalion Address: ��O � ��C.^�`r �Je.. <br /> City: ��.-r� State: W� Zip: ���—� I <br /> Mailing Address(i(dilferent): ' <br /> Cily: State: Zip: � <br /> Email: �lp ,r�3� Qct`r'�t�rl�lhk .'��� Phone: (41� 1�,°l — \�� <br /> , Total Cost to Instali Device(from contracrorinvoice):$ �� 5�0 ��� <br /> � <br /> Please verify the following: <br /> � I am the owner of the property where the backwater prevention device was installed. <br /> ' �o I worked with the conlractor lo determine the location for the backwater prevention device and <br /> undersland thal the decision regarding the location o(the device was mine. <br /> � � My contractor instructed me how lo access, inspect,and maintain the device. <br /> i <br /> ; � I understand that I am responsible for mainlaining the backwater prevention device and keeping <br /> ', it in good working order, unless it is instailed in the ciry right-of-way. <br /> �f If I sell my property, I will make potenlial 6uyers aware of the backwaler prevention device and <br /> � the need lo inspecl and maintain it on a regular basis. <br /> � [�] I am enciosing all of the necessary paperwork(Use the yeilow Rebate Submittal Checktisq. <br /> I <br /> Select from the following: <br /> � The contraclor identi(ied downspouts or olher drainage Ilines lhat were connecled to my sewer <br /> � line (bet�veen my hause and the instalied device)and re�ioved,or rerouled them. <br /> I ❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and ihe installed device). <br /> j � There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the inslalied device). I understand that leaving these connections creates a risk of tlooding <br /> and 1 accept ihat risk. <br /> � Slgnature Date � ���`.. �� ��� � � <br /> � <br /> y • <br /> I <br />