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i <br /> s <br /> i <br /> i <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> { <br /> Property Owner Name: <br /> Installation Address: A <br /> city: ���y��c - State: U-9 A- Zip: k2o k <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> 9 <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (from contractor invoice): $ �[ l• C� j <br /> t <br /> z <br /> Please verify the following: <br /> <1 am the owner of the property where the backwater prevention device was installed. <br /> I worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> My contractor instructed me how to access, inspect, and maintain the device. <br /> 1 understand that 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 sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> i <br /> 1 am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> line (between my house and the installed device) and removed, or rerouted them. <br /> t <br /> ❑ To my knowledge, my property has no downspouts or other drainage connected to 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 installed device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> t <br /> t <br /> Signature<�z <br /> Date <br /> I <br /> F <br /> 2 <br />