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Backwater Preventian Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: S7�_Q� 1�Q L! -�j �u 17 <br /> v <br /> Installation Address ��� �L_ y)7C[,�� 7� <br /> City�. � 11 e)" P�State: L(�Gl� _Zip:���-�� <br /> Mailing Address (il dillerent): <br /> City: State: Zip: <br /> Email: Phone: (+f,i5��`J-�•/✓�� <br /> Total Cost to Install Device (from contracforinvoice): 5 _ <br /> Please verify the following: <br /> ✓d I am the owner of lhe property�vhere the backwater preveNion device was installed. <br /> ❑ I �vorked v�ith the contractor to determire lhe location for the backwaler prevention device and <br /> understand that the decision regarding the locatio� of the device was mine. <br /> ❑ h�1y con;ractor inslructed me ho�v to access, inspect, and maiMain the device. <br /> ❑ I understand thal I am responsible for mainlaining lhe backwaler prevention device and keeping <br /> it in good working order, uniess it is instailed in the city righl-of-way. <br /> ❑ If I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the n�ed to inspect and maintain il on a regular basis. <br /> ❑ I am enclosing all of lhe necessary papenvork (use the yellow Rebate Submittal Checktist). <br /> Select from the following: <br /> ❑ The conUactor identified c+ownspoids or other drainage Ilines that were connected to my sewer <br /> lir,e (be6veen my house and thc installed device)and removed, or rerouted them. <br /> �o my knowledge, my property has no doemspouts or other drainage connecled to my sewer line <br /> (bebveen my house and ihe iestalled device). <br /> � There are do�vnspouts or other drainage lines connected lo my sewer line (between my house <br /> a��d ihe installad device). I understand thal leaving these connections creales a risk o(Oooding <br /> and I accept that risk. <br /> ,�:u� f�J� �rZ�-�S <br /> Signature� f Date <br />