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Backwater Prevention Device Rebate Program <br />Rebate Application Farm <br />Prope�ty O�vner Name: <br />� <br />3 � 3 � li,�kes �r�-v <br />Inslallation Address: ' — <br />City: /... (IPiC'Q� State �' Zip: y��U i <br />M. �ng AddrPss (il dilferenq: �S/�m E � <br />City: Slate: Zip: <br />Emaii: Phone: (�1�5} .? � y—.� 7 c�'9 <br />ef <br />Total Cost to Install Device (l�rorn confractorinvoiceJ: S 2 S� �� — <br />Please verify thc following: <br />� I am ihe o�vner of the preperty where the backwater prevenlion device voas installed. <br />❑ I worked with the contraclor to determine the location for the backwater prevention device and <br />understand that the decision regarding ihe location of the device was mine. <br />� My contractcr instrucled me how lo access, inspect, and mainta n the device. <br />❑ I understand lhat I am responsible for maintaining the backwater prevention device and keeping <br />it in aood working order, unless it is installed in the city right-o(-way. <br />� If I sell my property, I will make potential buyers a�vare of the backwaler prevention devicc and <br />Ihe need to inspect and maintain it on a regular basis. <br />❑ I am enclosing ali of the necessary papenvork (use the yello�v Rebate Subm�ltal Checklist). <br />Select from the tollowing: <br />❑ The contraclor identified do��nspouts or utner drainage Ilmes that were connecled to my sewer <br />line (behveen my house and the installed device) and removed, or rerouted Ihem. <br />� To my knowledge, my properly has no downspouts or other drainage connected to my se���er line <br />(beM�een my house and the installed device). <br />[] There are dovanspouts or other drainage lines connecled lo my se�ver line (belween my house <br />and .he installed device). I understand Uial leaving lhese conneclions creates a risk of flooding <br />and � accept that risk. <br />Signature������ Date S - i–.�o /5 <br />��� <br />