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� <br />� <br />Backwa�er Prevention Device Rebate Program <br />Rebate Application Form <br />Properfy Owner Name: C�'_ �.l��C.J�.��� `�",--.��)i�l�� ��C.���S� <br />lnstallation Address: ,..�'�`?c��� \'��(�' �1.� ���-• <br />City: ��)�{`-�`'�� State: ����, zip;� <br />Mailing Address (if differenij: <br />City: <br />State: <br />Zip: <br />Email: �. I l ZCC�.-'Ct�,� I�J' C.} l�t.l'OpIG � CC�fYI Phone: (��� �-�� "�� 4. � <br />7otal Cost to Install Device (from contracforinvoice): $ �,���' �� <br />Please verify the fol[owing: <br />� I am the owner of the property where the backwafer prevention device was instafled. <br />�I warked with the contractor to determine the lacatian for the backwater prevention device and <br />understand that the decision regarding the location of #he device was mine. <br />�j My contractor instructed me how ta access, inspect, and maintain the device. <br />�I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in fhe city right-of-way. <br />� If I sell my property, I wilf make potential buyers aware af the backwater prevention device and <br />� the need to inspect and maintain it an a regular basis. <br />[� I am enc[osing alf af the necessary paperwork (use the yellow Rebafe Submittal Checklist}. <br />J" <br />�Select from the fallowing: <br />❑ 7he contracfior identified downspouts or other drainage llines that were connected to my sewer <br />fine (between my house and the installed device) and removed, or rerouted them. <br />To my knawfedge, my.property has no downspauts or other drainage connected to my sew�r line <br />(between my house and the installed device). <br />❑ There are downspouts or afher drainage lines connected to my sewer line (between my house <br />and the installed device). 1 understand that leaving fhese connections creates a risk of floading <br />and I accept that risk. <br />Signature <br />Date � <br />