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, <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Properly Owner Name: �%I � ���'7 L�ti �/'� s "e/v�C� <br /> InstallalionAddress: �1� "� ��� <br /> City: V State: LI�-� Zip: �� �� <br /> Mailin �Address(ildifferenQ: � � �f� ��- � �� <br /> City: D � � I State: VJ A Zip: � 1S�7 b� <br /> Email: �v S 0 �(nNJd Q wY.us' -CJrV�Phone: (��) �2i (�" 7�7� <br /> Total Cost to Install evice(lrom confrac or invoice): S <br /> Please verify the following: <br /> �am the owner of the property where the b2ckv:ater prevention device was installed. <br /> ��ked with lhe contractor to determine the Iocation for lhe backwater prevention device and <br /> understand fhat the decision regarding the location of the device was mine. <br /> 0�y contractor inslructed me how to access, inspecl, and maintain the device. <br /> ��1 understand that I am responsible for mainlaining the backwater prevention devir.e and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> Di(f I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> lhe need to inspect and maintain it on a regular basis. <br /> �I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklisl). <br /> Sclect from thc following: <br /> ❑ ihe contraclor identified downspouls or olher drainage Ilines lhat were connected to my sewer <br /> line.(belween my house and the installed device)and removed,or rerouted them. <br /> �]�my knowledge,my properly has no downspouls or other drainage co^nected lo rrry sewer line <br /> (bet;�een my house and the installed device). <br /> ❑ There 3re downspouls or olher dr inage lines connected to my sewer line(betvaeen my house <br /> and the inslalled device). I unde tand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> l / • <br /> Signature Dafo �� � '�` /�� <br />