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b <br /> E <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: M 1d k eti✓ L CI-0Se--r <br /> Installation Address: _ I 'c? U ✓cam r'n i'6FICC <br /> l <br /> City: State: Zip: i <br /> i <br /> Mailing Address (if different): <br /> City; State: Zip: <br /> s <br /> C <br /> Email: Phone: <br /> Total Cost to Install Device (from contractor invoice): $ , <br /> vu <br /> Please verify the following: E <br /> 16 I 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. Y <br /> My contractor instructed me how to access, inspect, and maintain the device, 3 <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 the city right-of-way. <br /> k] 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 am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: t <br /> ❑ The contractor identified downspouts or other drainage alines that were connected to my sewer <br /> line (between my house and the 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 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 /> Signature r Date <br /> l <br /> x <br />