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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name� ' <br /> Instaliation Address:�� a l � � _ <br /> City:�JP�r� T 7 State: �✓�_Zip: � ��� <br /> Mailing Address(i(differenf): __ <br /> City: State:_ Zip' <br /> Email� � Phone: (�) � �Ii�C�'�3,��p <br /> � �p� � _ <br /> Total Cost to Install Device (Iram contrac(or invorce): 5�p '• <br /> Please verify the following: <br /> �I am the owner of the property where the backwater prevention device was installed. <br /> � � I worked with the contractor to determine the localion (or ihe baakwaler prevention device and <br /> understand that the decision regarding tne location of the device�vas mine. <br /> � My conlraclor insWcted me how lo access, inspect, and maintain the device. <br /> [�I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> rt in good�vorking ordcr, unless it is installed in the city right-of-way. <br /> � If I sell my property, I will make potenlial buyers aware of lhe backwater prevention device and <br /> Ihe need lo inspect and maintain it on a regular basis. <br /> ❑ I am enclosing all of Ihe necessary papenvork(use the yellow Rebate Submil�al Checklisl). <br /> Select from the following: <br /> ❑ The conlractor idenlified downspou�s or other drainage Ilines that were connected to my sewer <br /> line (behveen my liouse and lhe installed device) and removed,or rerouled them. <br /> �,�To my knowlr.dge, my property has no downspouts or other drainage connecled to my sewer line <br /> (belwcen my house and lhe installed device). <br /> � There are downspouts or other drainage li�es comiected to my sewer line(belween my house <br /> and Ihe inslalied device). I undersland thal leaving these connections creates a risk of(looding <br /> and I accept Ihat risk. <br /> Signature_ n�/.w Late � �v�� <br /> . / <br />