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Backwater Preven#ion Device Rebate Program <br />Rebate Appiication Form <br />Property Owner Name: ��,�.�, �, �' 4.,.r .: �� <br />lnstallation Address: �� �� N''� � c�-:��, ct� �`( �t.t, <br />City: State: Zip: <br />Mailing Address (if different): <br />City: Siate: Zip: <br />Email: Phane: ( ) <br />Total Cosi to lnstal! Device (from confracfor irtvorce): $<�� �%v R`''� <br />Ptease verify #i�e following: <br />m the owner of the property where the backwa#er prevention device was instal�ed. <br />I worked with the contractor to determine the location for the backwater preveniion device and <br />understand that the decision regarding the location of #he device was mine. <br />�My ontractor instructed me how to access, inspect, and maintain the device. <br />f nderstand thak I am responsible far maintaining the backwater prevention device and keeping <br />it in oad working order, unless it is instafled in the city right-of-way. <br />I self my property, I will ma4ce poten#ial buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. - <br />�m �nclosing all of the necessary paperwork (use the yellow Rebate Submittal CheckEist). <br />Select from the �Folfawing: <br />❑ The c ntractor identified downspouts or ather drainage Ilines tha# were connected to my sewer <br />line etween my house and the installed device) and removed, or rerouted them. <br />o my knowledge, my property has no downspouts ar ather drainage connected to my sew�r line <br />{between my hause and the installed device). <br />❑ There are dawnspouts or other drainag� lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flaoding <br />and I accept that risk, <br />Signature Dafe C � J/�� <br />