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�,. <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: / CJ��1�1 C' Le �'Z �G�- - ' ' <br />�. � 1 <br />InslallatlonAddress:_�C��ZC� �J�E'_��"1— j'��X,4�11�R_ �1LQlJ p <br />City'"� l L�t-Q7� _ Stale: .�� -- ZiP:�.''� <br />Mailing �ddress (i(dilferenQ: <br />City: <br />Emall: <br />State: ' <br />Total Cost to Instali Device (/rom contracforrnvoiceJ: $ <br />Please verify the following: <br />Phone:( <br />I am ihe owner of the property where the baclnvater prevention device was installed. <br />�orked with the contractor to determine the localion for ihe backwater pravenlion device and <br />understand that Ihe decision regarding the location of the device was mine. <br />�y conlractor instruded me how ro access, inspecl, and mainlain the device. <br />I understand lhat I am responsible for maintaining ihe backwater preven6un device and keeping <br />it in good worlcing order, unless il is installed in the city right-ot•tvay. <br />� <br />[� {f I sell my property, I will make pot�ntial buyers aware o( the hackwater prevention device and <br />the need to insped and maintain it on a regular basis. <br />� am endosing all of lhe necessary papervvork (use the yelluw Reb:,te Submittai Checklist). <br />Setect from Ne following: <br />❑ The conlraclor identified downspouts or other drainage Ilines lhat wem connected to my sewer <br />line bPt.veen my house and the installed device) and romoved, or rerouted them. <br />o iny knowledge, my property has no downspouts or other drainage connected to my sewor lino <br />(belween my house and the inslalled devico). <br />❑ There are do�vnspouls or other draina�e Iines xnnected to my sewer line (beRveen my house <br />and 1 �e installed device): I understand !hal leaving these conneclions creates a risk of Oooding <br />and t accept U!al risk. <br />� ' <br />C /J �-, <br />Signahue��� - Datc CjG�i _ / _ / j -- <br />