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1 <br /> i <br /> 4 <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: <br /> reJ1 � <br /> Installation Address: <br /> City G^c <br /> y: State: Zip: <br /> Mailing Address (if different): <br /> City: State: Zip: <br /> Email: Phone: { ) <br /> Total Cost to Install Device(from contractor invoice).$ S�✓� <br /> i <br /> l <br /> Please verify the following: <br /> I am the owner of the property where the backwater prevention device was installed. <br /> [�1 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 /> 3 <br /> [� My contractor instructed me how to access, inspect, and maintain the device. <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 /> d if 1 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: <br /> ❑ The contractor identified downspouts or other drainage (lines that were connected to my sewer <br /> line (between my house and the installed device)and removed, or rerouted them. <br /> E�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 /> t <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. r <br /> i <br /> Signature Date <br /> 3 <br /> _ t <br />