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Backwater Prevention Device Rebate Program <br /> Frr <br /> Rebate Application Form <br /> � <br /> Property Owner Name: �-� ���Q� Kr��i�;� <br /> I�slallation Address: I � I ��1�KF� T <br /> City: (� Il��� � State:�Zip: q� � j <br /> Mailing Address (i(diKerent): <br /> City: State: Z�P <br /> Email: Phone: ( ) <br /> Total Cost lo Install Device(/rom contrecfor invoice): $ � �� � � <br /> Please verify the followi�g: <br /> �I am the owner of the properly whera the backwaler prevention device was installed. <br /> �worked with ihe conUactor to determine the location for the backwater prevention device and <br /> understand that the decis�on regardmg Ihe location o(fhe device was mine. <br /> �My contractor instructed me how to access, inspect, and maintain ihe device. <br /> �understand that I am responsible (or maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is instalied in the cily right-of-way. <br /> If I sell my property, I will make potential buyers aware ot the backwater prevention device and <br /> the need to inspecl and mainfain it on a tegular basis. <br /> I am enclosing all of ihe necessary papenvork (use the ycllo�v Rebale Submittal Checklist). <br /> Select from thc following: <br /> ❑ The coMraclor idr,nti(ied downspouts or other drainage Ilines thal were connecled to my sewer <br /> line (belween my house and thc installed device) and removed, or rewuted them. <br /> �] To my knowledge, my property has no downspouts or other drainage coonected to my sev�er line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connecled lo my sewer line (between my house <br /> and the installed devicej. I understand ihal Ieaving these conneclions creates a risk of flooding <br /> and I accept that risk. <br /> Signatu►e I o �/�7�U�JVI � Datc_�1 r� <br />