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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />� Property Owncr Name. � <br />� Installa„on Address: _� _� <br />� City (Zv�1r�� I <br />I� tclailing Address Q(different): <br />r1 <br />� <br />r � - . <br />sca��: V" �- _ z��. �� % <br />City: _ State: _�_ Zip: <br />���o�— �,(• �� <br />Finail: �S' ZJ t �{'�'1�� Ju^Phone:(��Zj)'�-%Z2 `' �— <br />, Total Cost lo Install Devic2 (from contracfor invoice): S <br />Please verify the following: <br />� am the ovmer o( lhe property H�here the back�vaier prevention device v:as installed. <br />��I r�orked v�ith the coMractor to delermine the location tor the backvraler prevention device and <br />f�understand ihat lhe decision regarding ihe locatio� of tne device �vas mine. <br />i�-1y contraclor inslructed me ho�v to access, inspeG, and mainlain the device. <br />��understand lhaf I am responsible for maintainin� lhe hackwater prevention de��ice and keeping <br />it in good �vorking order, unless it is installed in the city right-ot-way. <br />U' If I sell my property, I �vilt make polenlial b�yers a��are of the backwater prevention device and <br />lhe necd to inspect and mainlain il on a regular basis. <br />�I am enclosing all of the necessary paperxork (use ihe yello�v Rebale Submiltal Checklist). <br />Sele t fjofn the following: <br />//� <br />`ihe contraclor idenhfied do�vnspouts or other drainage Ilines that �vere connected to my sewer <br />line (behveen my house and Ihe mstalled dr.vice) and removed, or rerouted them. <br />�o my knowledge, my property has no downspouls or other drainage con�ected to my sewer line <br />(behveen my hause and the inslalled devicej. <br />�� There are do�vnspouts or other drainage lines connecled to my sewer line (between my house <br />and the installed �evice). I understand thal leaving ihese conneciions creates a risk of Oooding <br />and I accepl that risk. <br />� �1 <br />Signature��.% ��� ������� Date�� <br />