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�,�}� Backwater Prevention Device Rebate Prograrn <br /> �'��F,., Rebate Application Form <br /> ��"J-- - <br /> Property Owner Name I Y�a�'U�' l �'�ne� — <br /> Installat�onAddress ��'�� h�I�/"`� S� <br /> J �!L ,� 1 Q� J <br /> City: �Ue��e7� W� State. W� Z�p �O � <br /> Mailing Address(d diNercnt). — <br /> . Cily: _ Sta;e Zip <br /> EmaiL Phone ( ) ---------���f�----�� <br /> Total Cost lo Inslall Uevice (Irom confracfor invoice): $ b��)"14 � <br /> Plcase verify thc following: <br /> �. i am the owner of the property�vhere the backwater prevention device was instal!ed. <br /> � I worked t:��th Ihe contractor to determine the location (or ti�e back�n�ater prevention devi�e and <br /> understand that ihe decision regarding the location of the de!it�was mine <br /> � My contractor �nslructed me how to access, inspect, and mainlam tho device. <br /> � I understand that I am resoonsible (or m3intairing Ihe backwaler prevention device and keeping <br /> il in good working order, unless it is installed in the ciry right-of-way. <br /> k�] If I sell my property, I will make potenGal buyere aware oi ihe backwaler prevention device ana <br /> the need to inspecl and maintain it on a regular basis <br /> �i I am enclosmg all of the necessary papenvork(�se the yetlow Rebale Submittal Checklisq. <br /> Select from the following: <br /> � The contraclor idenlified downspoWs or other drainage Ilines that�vere connecteA ro my sewer <br /> line (between my house and the installed device)and wrnovetl, or rerou�ed lhem. <br /> � To my knowledge, my property has no downspculs or other drainaye connected to my sew�er�ne <br /> (between my house and the inslalled device) <br /> � There are downspouts or olhar drainage lines connecled to my sewer line(betwecn my house <br /> and the installed devlce) I understand lhat leaving these connections creates a risk of flooding <br /> and I accept tY at risk <br /> Signature ���'�� � �- �A�nl�Date�`� <br />