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� Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner tJame: <br />Inslallation Address: <br />Ciry:�,� SlaleV��Zip: ��S�c�� <br />fulailing Address (if d;lJemnt): <br />City, <br />State: <br />Zip: <br />Email: �1��_ O�S� �(�jo{'ti�ntv (. Ga� Phone: (qz5) 3�-� —2-30g <br />Total Cost to Install Device (Irom contraclorinvoice): 5�',, -�`J <br />Please verify the following: <br />j�' I am the ow�ner ot the propedy where ihe backwater prevenfion devieo �vas installed. <br />[�'1 worked wilh the coniractor to determine the iocetion tor the backwater prevention device and <br />undersland thal the derision regarcimg Iha Iocation of the device was mine. <br />[yMy cont�actor insVucted me how to eccess, inspect, and maintaln tho device. <br />Q' I understand that I am responsible for matntaining Ihe backwater prevenUon dev(oe and keeping <br />it in good working order, unless it is inslailed in the city right-of-way. <br />� It I s�ll my proporty, I will mako potential buyers aware o(the backwater.prevention device and <br />the need to inspect and mainfain it on a regular basis. <br />0' I am enclusing all of IhH necessary papenvork (use Ihe yellow Reb�le Submiltal Checklistj. <br />Selectfrom the following: <br />❑ Tne conlractor idenUfied downspouts or oiher drainage Ilines that wero connected to my sewer <br />Ifne (belwevn my house and lhe mslalled device) and removed, or rerouled ihem. <br />[j� To my knowledye, my property has no downspouts or olher dralnage connecled lo my sewer 11ne <br />"\(betwee� my house and Ihe instalied device). <br />❑ Thete are dp�vnspouls or olhor drainage lineS Conneclad lo my sewer line (between my hou�e <br />and. lhe inslalled device). I understand that learing these conneclions creates a•risk ot Iluoding <br />and I accept that risk. <br />Signature�V(__� _ Date �i �% Zo`S <br />