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a <br />� <br />�ackwater Prevention Device Rebate Program <br />Property Owner Name: <br />f2ebate Application Form <br />� <br />Installation Address � �� �� � fJl/�✓ _ _ _ —.— <br />City: �V� . Stale: wN _ Zip: -( rl � I - <br />Nlailing Address (i(diNerent): <br />City: State: Zip: <br />[mail: VX.�Ul1� 1�1��1 �U7�'�C�-9-�� (n.Q�� Phone: (�� ) Z3 J�02 Z':.(,t�{ <br />Total Cost to Install Device ((rom contrac7or invoice): 5 �J �• �� <br />Please verify the following: <br />�I am lhe o� ner of the pmpe�ly wl�ere the back�vater prevenlion device was installed. <br />�worked wilh the contraclor to determine the location (or the backwater prevention device and <br />understand tha! the decision regarding the localion of the device was mine. <br />�My contractor instructed me how to access, inspect, and maintain the device. <br />�understand that I am responsible for maintaining the oackwater prevention device and keeping <br />d m good working order, unless it is installed in the city right-of-way. <br />�( I sell my propeii/, I will make potential buyers aware of the backwater prevenlion device and <br />the need to inspecl and maintain it on a regular basis. <br />❑ I am enclosing all of the necessary paperwork (use the yello�v Rebate Submiltal Checklist). <br />Select fram the following: <br />❑ The contracfor identified downspouls or olher drain��ge Ilines lhal were connecled lo my sewe� <br />line (6elween my housc and the installed device) and removed, or rerouted them. <br />�o my knowledge, my property has no dovmspouls or other drainage connected to my se�ver line <br />(between my house and the inslalled device). <br />❑ There are downspouts or other drainage lines connecled to my sewer line (bet �n my house <br />and the installed device). I undersland Ihat leaving lhese conr�eclions creates a n:,, flooding <br />and I accepl tha[ risk. <br />Signature ��^-�'��"� -' Dafe_ 3 Z�j f,� <br />