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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: 13, 1, ` I ' r LA�`'` •�' <br /> Installation Address:_ ( � ° `V1� <br /> City: State: Zip: + .2 <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (from contractor invoice):$ <br /> Please verify the following: <br /> di am the owner of the property where the backwater prevention device was installed. <br /> E l 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 /> VIcontractor instructed me how to access, inspect, and maintain the device. <br /> nderstand that 1 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 /> dl 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(lines that were connected to my sewer <br /> (between my house and the installed device)and removed, or rerouted them. <br /> ZTOMy <br /> 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 Date <br />