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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ovmer Name: _ <br />Installation Address: ��� X ��G ��� �� /�� <br />ciry: �I E? 2 E' 1� State: � �G' z�p:� � 2�� � <br />Mailin� Address (il diHerenc): <br />City: State: ZiA� <br />Email:��//1°� ���L7l2P (t- �! �L� (�1%1 Phone: ( ) <br />Total Cost to Inslall Device (from contrecrorinvoice): S�l �i 3�' S�Q <br />Please verify the followfnq: <br />� am the ovmer of the property �vhere the backwater prevention device was installed. <br />i <br />��I worked with lhe conlractor to determine the location for the back�vater prevention device and <br />understand that the decision regarding ihe location of ihe device was mine. <br />(-�My conlractor instructed me how to access, inspecl, and maintain the device. <br />��I understand that I am responsible For maintaining Ihe backwater prevention device and keeping <br />it In good working order, unless it is Installed in the ciry right-af-way. <br />❑� If 1 sell my property, I wlll make potential buyers aware ot lhe backwater prevention device and <br />ihe need to inspect and mamiain it on a regular basis. <br />� I am enclosing ail ol Ihe necessary paperv+ork (use ihe yellow Rebate Submitlal Checkiist). <br />Solect fram the following: <br />� The contractor (dentified dovrnspouts or other drainage Ilines thal were connected to my sewer <br />line (6enveen my house a�d lhc installed device) and removed, or rerouted them. <br />[CJ'� To my kno�vledge, my property has no downspouts or olher drainage conner.led to my sewer line <br />(behveen my house and the installed device). <br />❑ There are dcwnspouts or ulher drainage lines connecled to my sewer line (between my house <br />and the installed device). I undersland that leaving these conneclions creales a risk of Ilooding <br />and 1 accept Ihal risk. <br />e _ <br />%�%�� �� %r��, `� Z- ' - / � <br />SignaWre ��• � Dafe "- <br />