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� <br />� <br />Backwater PreVention Device Rebate Program <br />Rebaie Applica�ion Form <br />Property Owner Name: <br />Instailation Address: � l� � � <br />� <br />Ciry: �=� � ��� State <br />Mailing Address (if different): <br />rj <br />5( <br />City: State: Zip: <br />Email: C4�t �'L� �U i� �.. �> i� • C� Phone: {l'�"� �^5 �J� ��'c�.� <br />Total Cost to Install Device {from contractorinvotce}: $ ��c�` '� — <br />Please verify the fo{lowing: <br />�am the awner of the property where the backwater pre�ention device was installed. <br />�worked with the contractor ta determine the locatian for the backwater prevention device and <br />understand that the decision regarding fhe �ocation of the device was mine. <br />�My contractor instructed me haw to access, inspect, and maintain the device. <br />�E-ainderstan� that I am responsible for maintaining the backwater prevention device and keeping <br />it m good working order, unless it is instatted in the city right-of-way. <br />f i sefl my properiy, I wiA make potentiai buyers aware of ihe backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />I enclosing all of the necessary papenrvork {use the yelfow Rebate Submittaf Checklist). <br />Seleci fr m the foiiowing: <br />he contractor identified downspouts or other drainage Ilines that were connected ta my sewer <br />(ine (befinreen tny hause and the installed device) and removed, or rerauted #hem. <br />❑ To my knowledge, my praperty has no downspouts ar other drainage connected to my sewer line <br />(between my house and the ins#alled device). <br />❑ ihere are downspouts or ath�r drainage lines connected to my sewer line (befween my house <br />and ihe installed de�ir�). I understand fhat ieaving these connections creates a r�sk of ilooding <br />and ! accept that risk. <br />Date l � t ` <br />