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� <br />Backwater Prevention Device Rebate Pr��gram <br />Rebate Application Form <br />Property Owner Name: <br />0 <br />InslailotionAddress; �� � ��� 1� j/1/r <br />City: (�v� '/s7r State: l'J � Zip; � p�'� % <br />Mailing Address (if dillerenfJ: <br />City; State: Zip: <br />Email: CI �!''�i'`-1 rt�� �4A'f`lY1diJ� i/r,�t Phone: ��� yD�• 5 75� <br />Totai Cost to Insta" Oevice (from contractor invotce)� 5 �y SrX�./� <br />Please verify the lol�owing: <br />�n Ihe o�vner ot the propeHy where the backwater prevendon device was mstallod. <br />" I worked wdh the contractor to detennine the IoGation for the i�ackwaler prevention device and <br />u ersland that the decision regardfng Ihe loc0lion ot the tlevicF vras mine. <br />� My conlracbr instrucled me how to access, inspool, and main the device. <br />�1 undersland that I am rosponsible tor maintaining 1he backwater prevention dev�ce and keeping <br />it in good working order, unless it is instalied in lhe cily right-ot-way. <br />lf I se11 my propedy, I will make potential buyers aviare a( Ihe baekwatar pr8vahlion dovice and <br />lhe need to inspect and maintain it on a regular basis. <br />I am enclosuig all oi 1he necessary papenwork (use Ihe ysllo�v Rebate Submiltai CFiecklist). <br />5elett from the fo�lowing: <br />❑ Tho contraelor idenli(ied downspouls or olhet drainage Iflnes that v�ere connecled to my setvn_r <br />lfne (6etWeen my house and Ihe installed dewceJ and removed, or rerouted them. <br />� To my knowledge, my property has no downspoUls or olher rtrainaqe connected 10 my sewer line <br />(bolween my house and ihe inslalled device�. <br />❑'fhere are do�erspouls or other drainage Imes connectad tb my sewer lina (between my house <br />and Ihe installed device). I understand Ihat leaving these connections creates a nsk oi floodh�g <br />and I accept Ihat nsk. <br />Signature � " {uG�v�^'�k`'"- ..l���atc � 3�/� � <br />� �--- <br />