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Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Properly Owner Name: ��[_bC�L � a..� C Q�O � i���L <br /> Instaltation Address: �q � 8 �oc ke�P 4'�e <br /> City:��P.fP.��._ State: 1A�� zi�: "� � 2�l <br /> Mailing Address (iI diKerenQ: �� <br /> City: ____ State: 2ip:_ <br /> Email: _ Q� �("���L1�_GC�21_ Phone (�� Z l 0'c{'�U�" <br /> Total Cost to Install Device ((rom confractorinvoice): Y a. � �_� <br /> Piease verify the following: <br /> �am lhe owner of the property where ihe backNater prevention device was installed. <br /> �I worked wilh the contraclor lo determine lhe locati.^ 'ie backwaler prevenlion device and <br /> understand lhal the decision regarding the location �i �he device was mine. <br /> �My conlraclor instrucled me how to access, i�spect, and maintain the device. <br /> �J I understand thal I am responsible for maintaining the backwater prevention device and keeping <br /> ;t in good vvorking order, unless it is installed in the city rlght-of-�vay. <br /> � 17 1 sell my property, I wiil make polenlial buyers aware of ihe backwater prevention device and <br /> Ihe need to inspect and maintain it on a regular basis. <br /> 1 <br /> � I am enciosing all o(the necessary paperwork (use Ihe yellow Rebate Submitlal Checklist). <br /> Selec[from the following: <br /> �S �he contr:,c;or identified downspnuts or olher drainac�e Ilines that were connected lo my sewer <br /> v line (belween m i house and thc ina.talled device)and removed, or rerouled them. <br /> ❑ I o my knowledye, my property has no downspouls or other drainage connected to my sewer line <br /> (belv+een my house and the installed device). <br /> ❑ There are downspouls or olher drainage hnes conneGed lo my sewer line (betwcen my house <br /> and lhe installed device). I understand Ihat leaving these conneclions creates a risk of flooding <br /> and I accept that risk. <br /> � <br /> Signaturc Date__ � � U �S <br />