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�Backwater Prevention Device Rebate Program <br />E„ Rebate Application Form <br />Property0a�nerName: Rc-,}E rt.2.4'J�,�� <br />InstallationAddress' 3`1UJ. l�ocl�c�=l�Ct'— �9Ur' _ <br />City: ��c"��C tY _ State: �.� Zip: 9 S�LvI <br />Mailing Hddress (if diHerent): <br />City: Stale: <br />[mail: <br />Phone:( <br />Total Cos; to Ins,all Device (from contractor invoice): 5__ __ <br />: �aasc verify the following: <br />�j I am the oemer of the properry where the backwater prevention device was installed. <br />�,1 I worked with the conlracfor lo determine the location for lhe back�vater prevenl�on device and <br />under;tand that the decision regarding the location of the device ia�as mine. <br />f� N7y coMrector instructed me ho�v to access, inspect, and maintain the device. <br />j� I understand that I am responsible tor maintaining lhe back�mater prevention device and keeping <br />it in good �vodcing order, unless d is installed in the ciry right-o(-way. <br />�'j If I sell my property, I e:ill make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular bssis. <br />j� I am enclosing all of the recessary papenvork (use the yello�v Rebate Submittal Checklist). <br />Select trom the (ollowing: <br />The contrector identified downspouts or other draina 3e Ilines that were connecteci to my sewer <br />line (behveen my house and the installed device) and removed, or rerouted them. <br />� To my knowledge, my praperty has no downspouts or other drainage connected lo my sev:er line <br />(between my house and lhe installed device). <br />[� There are downspouts or other drainage lines connected to my sewer line (beM�een my house <br />and the instalted device). I untlersland that leav�ng thesr. conneclions creales a risk of floodirg <br />and I accept thal risk. <br />Signature � ; � _ Date �✓ ' .2 �—/S <br />