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� Backwater Prevention Device Rebate Program ; <br />R�bate Application Form <br />Properh� O�:uner Namc <br />D <br />InstallalionAddress: =�ff��__�%/� / <br />i /� <br />� --�f..��'�-�� y --P - -- <br />CiP : State' �/�- � Zi � �^-- <br />(�tailing Address (ildillerent): ��� � d . � ��� G��_ —� L—. <br />City: �}�j��'� State� L l.� _ ZiP:�, �� � <br />EmaiP`1 s�+� FLone� ( 1 <br />^ / <br />Total Cost to Install Device (Irom contractor invoice) $ ✓� 4(� <br />/ <br />Please veri;y the tollowing: <br />�j I am the o^�rer of !he proper;� c�nere the backv.�a;er prevr.nticn devicr. c�as ins�alled. <br />/ <br />� I vorked :�dh thc contractar to determine the location �or the backwater prevention device and <br />understc nd thal the deasion regarding the location of lhe d�vice was mine. <br />�_! <br />�J <br />My cortractor instructed me how to access, inspec[, and maintain �he dev�ce. <br />I un�ierstand that I am responsible lor maintaining the backveatr.r prevention dewce and I<eep�ng <br />it in go^d n�orking order, unless it is installed in the city right-o(-way. <br />j/� It I sell my property, I wiil make polential buyers aware of Ihe baclavater prevention device and <br />� the need lo inspect and main!ain it on a regular basis. <br />�I am encles�ng ail ot Ihe necessary paperv+on� (use the yel!o��� Rebata iubrnittal Chechlisll. <br />Select from �hc tollowiny: <br />j j The contractor identi(ind downspoulc or o�her drainage Ilines �ha! werr, cennected lo my se�.ver <br />line (oehveen my house and the installed device) and removed, or rcrouted thr.m <br />To my knowledr�e, my property has no downspouls or olher drainage connecled to my sewe�r linc <br />(bet�veen my house and the inslalln�l devicc). <br />(; There are dn�vnspouls or other drainage lines connected to my sewer line (hetween my hou;e <br />and the i�stalled devicel. I understand that leaving these conneGions r,reates a risk of floodiny <br />and I accept Ihat risk, <br />Signa <br />Date ��_ [��r_� <br />