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� Backwater Prevention Device Rebate Program <br />Rebate A�plication Form <br />IPicperty O�vner Name: ��ri� __ <br />I InstaL'atfor Address ' � /^�� �� / d-- ���T' <br />3'10� ��j��.� ��� � _ .�, - <br />� ,�(�.� /f � <br />I CirY ��1X1C te: �iT ---Zip: / �J _ <br />Mailing Address (i1 dillereni): __ __ <br />City: State: _ Zip: <br />EmaiL_ _-- —Phcne�� � ��������-� <br />I Total Cost to Instail Device (lrom conUactor invorc^): $_�t��(/ �� ___ <br />L--- — — <br />Please verity the following: <br />�I am ihe owner of the proper+y �vhere Ihe backwater prevention device was installzd. <br />< <br />j� I ivorked i��ith �.ie conlractor to datermine the localion lor Ihe Lack�vater preven;ion dev�ce and <br />understand t; at thr decision regarding the location of Ihe device was mine. <br />�My contractor :•structed me ho�v to access, inspect, and maimain ihe device. <br />� � understand that I am responsible for maintaining the backwater prevention device and kecping <br />�il in good v�orking order, unless it is installed in the city right-o(-way. <br />•�if I scll my properry, I will make poteniial buyers aware of the backwater prevenUon defice and <br />Ihe need to in,pect and maintain il on a regular basi;. <br />1`}. I am enclosing all of the necessary p2perworl< (use ihe yellav Rebate S�,bmittal Checklist). <br />Sclect Irom ihe tollowing: <br />f � TL� conlracloi identitied downspouts or olher drainac7e Ilines ihat tvere connected to my sewer <br />line (between my house rind ihe nutalled devicc) anJ removed, or rerouted ihem. <br />�To my knowledge, my prooerly has no downspouls or other drainac�e connected to my sewr.� i- <br />(betwecn my house and ihe in,lalled device). <br />j_1 There are downspouts or nihcr drainage lines conneded to my sewer line (bet�.veen my hr.usr. <br />and the instalied device) I understand that leaving ihese connections creales a risk of flocding <br />and I accept that �isk. <br />Siyna .. �!'_ � �te �_ � (1��� <br />1 <br />