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✓ <br />�a�kwaie� P�re�eniion D�vice Reba�e Program <br />Rebate �pplication F�rm <br />Property Owner Name: <br />lnstallatian Address: 3 �� � F�� �ti-r �/� <br />City: L verc,{� state: W� zip: �5'2d � <br />Mailing Address (ifdifferent): <br />City: State: Zip: <br />Email: l�hone: ( ) <br />Tokaf Cost to lnstall Device (from contractorinvoice}: $ �"f r�� -�� <br />Piease ver'sfy trhe folimwing: <br />� I am the owner of the property where the bactcwater preventian device was instailed. <br />�I worked with the contractor to determine the location #or the backwater prevention device and <br />understand #hat the decision regarding the locatian of the device was mine. <br />(�p My contractor instructed me how to access, inspecf, ar�d maintain the device. <br />T <br />�t understand that I am responsible for maintaining the backwaier preveniion device and keeping <br />it in goad working order, unless it is insta{led in the city right Qf-way. <br />�lf I sell my property, [ wiil 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 a11 ofthe necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Selec# frosn the following: <br />[� The contrac#ar identified downspauts or other drainage ilines 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 praperty has no downspouts ar other drainage connected to my sewer line <br />(between rny hause and the instailed de�ice}. <br />❑ There are downspouts or other drainage lines connecfed to my sewer iine (between my house <br />and the installed device). I understand #ha� leaving these con�ectians creates a risk of flooding <br />and 1 accept that risk. <br />Sognaiuve l� Date r[ vllls <br />