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Backwater Prevention Device Rebate Program <br /> 4.77. <br /> Rebate Application Form <br /> Property Owner Name: ....7";--- i 3 e--hCG c <br /> �7 <br /> Installation Address: c �O 9 {�-� " <y • <br /> City: _t tie(c-4---I--- State: t N r Zip: q gab <br /> Mailing Address (if different): ‘,94q On - <br /> x <br /> City: State: Zip: <br /> Email: c h-tVef & Qv f- CJ ) Phone: (-/ZS Z S Z:--Z/gig <br /> -- <br /> Total Cost to Install Device(from contractor invoice): $ c 4J- U <br /> Please verify the following: <br /> gr/1*.r-m the owner of the property where the backwater prevention device was installed. <br /> I worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> [tib My contractor instructed me how to access, inspect, and maintain the device. <br /> g I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> if <br /> 1:211 sell my property, I will make potential buyers aware of the backwater prevention device and <br /> th need to inspect and maintain it on a regular basis. <br /> I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> ❑ The contractor identified downspouts or other drainage !lines that were connected to my sewer <br /> line(between my house and the installed device) and removed, or rerouted them. <br /> Ei To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> rte--- <br /> g-- 5--,/ <br /> Signature Date <br />