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Backwater Prevention Device Rebate Program <br /> RebatQ Application Form <br /> Property Owner Name:���Sg <br /> � C`h2-ee �fi' <br /> Installation Address: 2 72 � �._ <br /> Cdy: �I +-P�Vl State: �iJ`�- Zip: Ql�-��� <br /> Mailing Address (ildiflerentJ: <br /> Ciry: State: Zip: <br /> Email: Phone: ( ) '�i 7-'y� �� <br /> u �� <br /> Total Cost to Install Device(fiom conf2ctor invoice): S� � <br /> Please verify the following: <br /> � am ihe owner of the property where the backwater prevention device�vas installed. <br /> �worked with the contraclor to determine the tocation for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> [�}iMy contractor insiructed me how to access, inspect, and maintain the device <br /> �I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the ciry right-of-way. <br /> �I seli my property, I v+ill make potential buyers aware of the backv�ater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> �I am enclosing all of the necessary paperv✓ork(use the yellow Rebate SubmiHal Checklist). <br /> Seleet irom the following: <br /> ❑ The contractor identified dovmspouts or other diainagt Ilines that viere connected to my setver <br /> line (between my house and Ihe installed device) and removed, or rerouted them. <br /> [��i'o my knowledge, my property has no downspouls or other drainage connected to my sewer line <br /> (behveen my house and the installed device). <br /> � There are downspouts or other drainage lines connected to my sewer line(belween my house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and i accept that risk. <br /> Signature �l/X,��7?�( � Date 12-1 L� -1 J <br /> [/ <br />