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1 <br /> 3 <br /> z <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: Xoon <br /> Installation Address: <br /> City: e State: Zip: <br /> Mailing Address (if different): <br /> City: State: Zip: <br /> a <br /> Email: Phone: ( ) I <br /> Total Cost to Install Device (from contractor invoice): $ <br /> Q <br /> Please verify the following: <br /> i <br /> 1 <br /> b/am the owner of the property where the backwater prevention device was installed. <br /> we 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 /> LJ/My contractor instructed me how to access, inspect, and maintain the device. <br /> LI 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. 1 <br /> r <br /> R <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 /> b/I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> I <br /> i <br /> Select from the following: <br /> ❑ The contractor identified downspouts or other drainage clines that were connected to my sewer <br /> line (between my house and the installed device)and removed, or rerouted them. <br /> tmy knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> -)(Abetween 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 E <br /> and I accept that risk. <br /> 4 <br /> Signature A,, Date i <br /> i <br /> k <br /> 4 <br /> i <br />