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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> � <br /> PropertyOwnerName: t�P� cy �1�Yl���/ <br /> Installation Address: 1�(�(� �Z'i��C��Q 1�f C' F"'C'`� e <br /> Ci,y: �vP_�e}1 State: Wf� Zip: 9 �SZo � <br /> � Mailing Address (il diHe�ent): <br /> City: Stale: Zip: _ <br /> Email: f,�����1��i��_�7E.�n, cr�ry� _Phone: (Y(b'f �LD 2?G�_ <br /> Total Cost to Instali Device (Irom contractor invoice): � �"�!�"8` <,S00 • 00 <br /> Please verity the following: <br /> � I am the owner of the property where the b�ckwater preventfon device was installed. <br /> 0, I worked with the contractor to determine the location For the backwater prevention device and <br /> understand that ihe decision regarding the location of the device was mine. <br /> � My contractor instructed me how to access, inspect, and maintain Ihe device. � <br /> � I understand that I am responsible for maintalning the backv�ater prevenlion device and keeping <br /> it in good working order, unlass it is installed in the ciry right-of-way. <br /> � If i sell my property, 1 witl make potential buyers aware of the backwater prevention device and <br /> lhe need to Inspect and maintain it on a regular basis. <br /> � I am enclosing all of the necessary pape�,vork(use the yellow Rebate Submittal Checklist). <br /> Select lrom the following: <br /> [� The contractor identified downspouts or other drainage Ilines that were connected lo my sewer <br /> line(behveen.my house and the installed device) and removed, or rerouted lhem. <br /> -�� To my knowledge, my property has no downspouts or other drainage connect��d to my sewer line <br /> (behveen my house and the inslalled device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br /> and ihe inslalied device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Sfgnature i � _ �" Date S f a 3�5 <br /> � <br />