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Backwafier Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: ��-�5�� �Q�_�_._ <br />Installation Address: ��rZ--� �-�.1`�--- f�CV� . <br />City: ���� 1 1 State: Zip: ���� 1 <br />Mailing Address (if different}: _rj��t,,.. �'� ��OV�p... <br />City: <br />State: <br />Zip: <br />Email:-j�l�{�.P��Y (�I�.�d Y�C�� � C�VIh. Phone: (� �(- 2l 2� <br />r �.'� � <br />7otal Cost to Install Device (from confractor invoice): $`�..,�� )� <br />Ptease verify the foltowing: <br />� I am #he owner of the property where the backwater preventian device was installed. <br />I warked with the contractor #o determine the location for the backwater preventian dgvice 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 />��� <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 />�If l 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 />Seleci from the following: <br />❑ The contractor identified dawnspouts or other drainage Ilines ihat were connected to my sewer <br />line (between my hause and the installed device) and remaved, 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 sew�r line (between my house <br />and fhe installed device). 1 understand that leaving these connections creates a risk of flaoding <br />and I accept that risk. <br />t. � <br />Signafure � Date �l� '' ���-'� � �� <br />