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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property �Wner Name: <br />Installation Address: <br />r�; <br />State: �`.✓� —7ip:�= <br />Mailing Address (if diNerent): �-J�'� <br />City <br />•�-V.P�,Lz!' Stale: � Zip: / � �� <br />Phone: ( ) ---- <br />EmaiL �� �, --- <br />Total Cost to Install Device (�rom contractor invoice): $ <br />Plcasa verify the followin9: <br />'� I am the owner of the property where the bar,kwater prevention device was instalied. <br />�I worked with the contraclor to determine lhe location tor the backwate: prevention device ano <br />understand thal Ihe decision regarding the location ot the device was mine. <br />� My contraclor inslrucled me how lo access, inspecl, and maintain lhe device. <br />�I undersland thal I am responsible for maintaining the backwater prevention device and keeping <br />il in good working order, unless il is inslalled in fne city right-oi-way. <br />['�I( I sell my propehy, � W��� �nake polential buyers aware ot 1he backwater prevenlion device and <br />lhe need to inspect and mainlain il on a regular basis. <br />r( � I am enclosiny all oi the necessary paperwork (use the yellow Rebate Submitlal Checklist). <br />r-� <br />Select tram thc foliowing: <br />C-I � he (belwec1n my ho'u1se and thc nsla�ed devic�c)I�ndrelmoved?or rerouted theind to my sewcr <br />�1"o my knowledye, my p�operiY has no downspouls or other drainage connected to my sewer linc <br />(between my house and lhe inslalled device). <br />t� andrthe'in salled device)r I u'nderstand Ihal leav ng�these co nectlons creates`a rsk of tlood'nc� <br />and I accept that risk. <br />� � <br />� '✓�� �� <br />� �`�— Date �-- <br />Signalure <br />