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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name ��RtO t 1'V��L/��} /t CL G?TlIc2D <br /> InstallationAddress: �� Z, ����N� �E <br /> City: EJ��2�.=r; state:W�'` zip: �1�� ( '-' 150� <br /> F,Aailing Address(if ddlerentJ: <br /> Ciry: State: Z�p: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (Irom confracforinvoice): �__ <br /> Please verify the following: <br /> dl am the owner of the property where the backwater prevention device was installed. <br /> [v]�I worked v�ith the coniractor to determine the tocalion for ihe backwater prevenlion device and <br /> undersland that lhe decision regarding the location of the device was mine. <br /> ✓�My contraclx instructed me how to access, inspect, and maintain the device. <br /> [�I understand lnat I am responsible for mainlaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> �'If I sell my properly, I will make polenlial buyers aware of the backwater prevenlion device and <br /> the need to inspect and maintain it on a regular basis. <br /> [�I am enclosing all ot the necessary papenvork(use Ihe yellow Rebate Submittal Checklist). <br /> Select fram the following: <br /> � The contractor identified downspouts or other drainago Ilines that were connecled to my sewer <br /> line(belween my house and !he instail-�device) and removed, or rerouled Ihem. <br /> [�{To my knowladge, my property has no downspouts or olher drainage connected to my sewer line <br /> (hehveen my house and the installed device). <br /> ❑ There are downspouts or other drainage iines connecled to my sewer line (between my house <br /> and the instalied device). I undersland ihal leaving these connections creates a risk of flooding <br /> and I accept ihat risk. <br /> Signatore"V�l�c.," I.Q)�� Date �� ��5 <br />