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� <br />Backwa#er Prevention Device Rebate Program <br />E�, Reba�e Application Form <br />Property Owner Name: P0.T1^l�- <br />Installation Address: 3 3 � � � ��'� �' <br />� <br />v�n� <br />City� EU H,f� `� State: �� Zip: ���d � <br />C�Ci 11�n <br />Mailing Address (if ditferent}: ��� c� 4 M C� p. ��[� , N:� <br />City: j�t r`l 1 ri Q-fp�1-� State: �/lf A Zip: 9��.-� <br />,. <br />Email: � A�FC t-'��i � 1'riSYI., �-Orr't i�hone: �f�C� �e5� 7�1''i(9 <br />Tofai Cost to Install Device (from contractor invoice): $ <br />Please verify the following: <br />�j f am the owner of the property where the backwater prevention device was installed. <br />� f worked with Ehe conEractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location o# fhe device was mine. <br />� My contractor instructed me how to access, inspec#, and maintain the device. <br />{� I understand thai I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />[� If I sefl my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain i# on a regular basis. <br />[_� I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />��f '1'he contractor iaentified do�vnspouts or other ds�ainage Ilines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />�] io my knowledge, my property has no downspouts or other drainage connected ta my sewer line <br />(between my house and the installed device). <br />�] There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the instaiEed device). I understand that leaving these cannectians creates a risk of flooding <br />and I accept that risk. <br />Srgnature `� Date �� r,� r v2��.5� <br />