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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property O�vner Name: <br />!� <br />Inslailation Address: �� �- � �� ��-�� �1 e� r,� <br />City: �V�=VGiT s���e _Y✓.A z�p: �18ZO I <br />Mailing Address (il drlferenlJ: I I D� l�VG %�2 P � I/�. <br />i City: L-� ✓'C�Y�'- j� State: �_ Zip:��� --- <br />�I Email: �Nd�r�eew� � aol , (.d�y� Phone:VZ���=�.5�0 <br />JU <br />i Total Cost to Install �evice (from co�d�actor invoice): 5 %� ��� — __ <br />Please verify the following: <br />I am the ovmer of the property where the backwater prevention device was installed. <br />I vrorkF.d with the contraclor to determine the location for lhe backwater prevention device and <br />under,tand that the decision regarding the locaticn o( the device v�as mine. <br />My contractor instructed me ho��+ to access, inspect, and maintain the devica. <br />�understand that I am responsible for mainlaining ;he backwater prevention dewce and keeping <br />it in good working order, unless it is instal�ed in lhe city right-of-�vay. <br />f I sell my property, I v�ill make potenlial buyers a�vare of the back�vater prevention device �nd <br />the need to inspect and maintain it on a reguiar basis. <br />�am enclosing all o( ihe necessary papenvork (use the yellow Rebate Submdtal Checklist). <br />Select from the tollowing: <br />��/ <br />e contraclor idenlified do�•mspouts or other drainage Ilines lhat were connectod to my see,er <br />hne behveen my house and !he installed device) and removed, or rerouled them. <br />! o my kno�vledge, my property has no tiovmspouis or other drainage connected to my se��er �ine <br />(between my house and the installed device). <br />❑ There are dovmspouts or other drainage lines connecled to my sewer hne (between my house <br />and the installed device). I undersland thal leaving these connections creates a risk of ilooding <br />and I accept that risk. <br />Si nawre � � Date � 2'� � <br />9 <br />