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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name:: <br />Installation Address: � <br />City. ,�.Q..1�-E._�_ State: <br />� <br />Zip:. IO w v <br />Mailing Address (i(di(ferent): / / !�' S! � `� � � l/_ t�� <br />City: �)i'i �� State: �/`�� Zip: � �7 �-9 a <br />Email: .. ,r �(.is ��Sn • L Phone: �y ! vp — O �Y <br />Tc:al Cost to Install Device (/rom coutractor invoice): $�_� `� �� O� <br />Please venfy Ne following: . <br />am the owner of the property where the backwater prevenlion device was installed. <br />[��orked with the conUactor to detertnine the location for the backwater prevention device and <br />understand that tfie decision regarding the location of the device was mine. <br />�� contrador instructed me how to access, inspect, and maintain the device. <br />�nderstand ihat I am responsi6le for maintaining the backwater prevention device and keeping ' <br />it in good working order, unless ft is Installed in the city righl-of-way. �. <br />[�IF1 sell my property, I will make potenUal buyers aware of the backwater prevention device and <br />the need to inspect and maintain il on a regular 6asis. <br />�am enclosing all of lhe necessary papenvork (use the yellow Rebate Submittal Checklist). <br />1/ ` <br />Select irom tfie following: <br />❑ The conlractor idenlfied downspouts or other drainage Ilines that were connected lo my sewer <br />linc (betweeamy house and the installed device) and removed, or rerouted them. <br />�my kno��iledge, my property has no downspouts or olher drainage connected to my sewer line <br />(between my house and the inslalled device). <br />❑ There.are downspouts or other drainage lines conneded to my sewer line (betwean my house <br />and the installed device). I understand tl�et leaving these connec0ons creates a risk of flooding <br />andl accept ihat risk. <br />Signature� �� � Date dG�" S�.Z��S_ <br />