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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Propetty Owner Name: �Gt+� ' � � <br />Installat'ton Address: ��% � � r� �� <br />City: State: <br />Mailing Address {if different): <br />City; <br />Email: <br />State: <br />Total Cast to fnsta{I Device (fram contractorfnvaice}: $ <br />Phone: (L/Zs ) �� � S/� � <br />Please verify the following: <br />�j I am the owner of the properfy where the backwater prevention device was instelled. <br />� I worked with the contractor to determine the location for the backwater prevention cievice and <br />unders#and #hat the decision regarding the locafion of the device was mine. <br />� My contractor instructed me how to access, inspect, and maintain the device. <br />�! understand fhat f am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is instafled in the city right-of-way. <br />� If I sefl my praperty, I wifl make potential buyers aware of the backwater preven#ion device and <br />the need to inspect and maintain it on a regular basis. . <br />� I am enclosing all of the necessary paperwork (use the yel�ow Rebate Submittal Checklist). <br />Selec# from the following: <br />❑ The contractor identified downspouts or other drainage llines that were connected to my sewer <br />line (between my house and fihe installed device) and removed, or rerouted them. <br />"�To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the insta{led device). <br />[] There are downspauts ar other drainage fines connected to my sewer line (between my house <br />and the installed device}. I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />� <br />Signafure` �'� � ��'���,���/�`" Daie � !�� �� <br />