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Backwater Prevention Device Rebate Program <br /> Rebate Application F�rm <br /> Prcoerty O�vner Name: _yy�l{,hM��( ZRhe� <br /> InstallalionAddress: /�'�,f�l (��-��P <br /> City: F.il P�'P�` State: c,./ �'1- _zip: `� i4 l JI <br /> Mailing Address(ifdiNerenf): <br /> City _ _ State: Zip <br /> Email: Phone: ( ) <br /> Total Cosl to Inslall Device (from contrectorinvoice): S ���Lgq <br /> Please verify the following: <br /> �am the o�vner of lhe property v�here Ihe backv�ater prevenlion device was inslalled. <br /> �worked with the conlractor lo delermine the location for lhe backwater prevention device and <br /> understand ihat the decision regarcling lhe location of the device was mine. <br /> [�My contractor insiructed me how to access, inspect, and maintain the device. <br /> �understand that I am responsible for maintaining the backx�ater prevenlion device and keeping <br /> it in good working order, untess it is inslalled in the city right-of-way. <br /> �t I seli my property, I will make potential buyers aware of lhe backwater prevention device and <br /> the need to inspect and maintain d on a regular basis <br /> [�m enclosing all oF the necessary paperwork (use the yelloe+ Rebato Submiltal Checklist). <br /> Sclect from the following: <br /> ❑ The contractor identified downspouls or olher drainage Ilines that were connected lo my se�ver <br /> line (between my house and the instailed device) and removed, or rerouted lhem. - <br /> To my knowiedge, my property has no downspouts or olher drainage co�nected to my sewer line <br /> (between my house and the installed device). <br /> ❑ Thcre are downspouls or other drainage lines connecled to my sewer line (bebveen my house <br /> and lhe inslalled•device). I understand that leaving these connections creates a risk of flooding <br /> and I accept lhat risk. <br /> Slgnafure � � 7 rf �'1 �✓ Date G 1 � I » <br />