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Backwater Prevention Device Rebate Program <br />' Rebate Application Form <br />Property Owner Name� �ltr�aroc. ��� � �'� <br />Inslallation Address: a00 (��% r�ii A r �i �✓� <br />_7 <br />citv:_��J�r�`f�" state: GJH' zip� 9l'd0 / <br />Mailing Address (ildifferentJ: � r30��� �� 2 �c <br />c�ry: M, I � Cre e k siac�: _Gu� .__—. ziP: qk6 r�. <br />Email: �a�p llhP. nC> I� � f�rn ��• c1� nn Phone: (5����} �3 0_7J 6' `) <br />Total Cosl lo lnslall Device ((rom contractorinvolce): 5 <br />Please verify the following: <br />(�I am the o�vner oi lhe property where the backwaler prevention device was installed. <br />�worked wilh the contr;�ctor lo determine Ihe location for the bar.kwatcr prcvention device and <br />�nderstand lhal Ihe der.ision regarding thc location of the device was mine. <br />j�' My contractor inslrucled me how lo access, inspect, and malnlain the device. <br />�understand Ihat I am responsi6le lor mainlaininy the backwaler prevenlicn device and keeping <br />it in gocd working order, unless it is ins�alled in the city righ4of-way. <br />j�f I sell my property. I will make potential buyers aware oF lhe backwater prevention device and <br />the need to inspect and mainlain it on a rogular basis. <br />v I am enclusii�y .all of Uie necessary papenvork (use Ihe yello�v Rebale Submiltal Checklist). <br />Sclect from the following: <br />I_� The contractor identified downspouts or olher drainage Ilines thal �vere connecled lo my se�v^r <br />line (between my ho� se and Ihe installed device) and removed, or rerouled them. <br />�o my knowledge, my property has no dosvnspouts or oUier drainage connected to my sewer line <br />(belw�en my house and Ihe inslalled device). <br />� There are downspouls or other draina�e lines r.onnecled to my sewer line (between my house <br />and the inslalled device). I understand thal Icaving these connections creates a risk of flooding <br />and I ncr.ept that risk <br />/� /y > �/ <br />Signaturc�� �L'�'-t �' �"��%l Date S'z� -�f l J <br />