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� Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property O�vner Name: _ 1���"�^ ��` <br />Installalion Address: ��-i �� U� � C� r,� ,' c., <br />Cily; �%v�e-��d"� State: V13� <br />�vlailing Address (il di(/erent): <br />i City: <br />Email: <br />State: <br />Total Cost.lo Inslall Device (Irom confrec�orinvoice): 5 <br />� — <br />Zip: `� ?� cJ 1 <br />Zip: <br />Phone: ( ) <br />Please verify the following: <br />�I am the owner oi the property where the backwaler prevention device �vas installed. <br />�I worked wilh the contractor to determine the lo�tion fnr the backwater prevention device and <br />understand that the decision regarding the location of lhe device was mine. <br />Cv�My conlractor inshucted me how to access, inspect, and r-iainlain the device. <br />[�j I undersland that I am responsible for maintaining lhe backwater prevenlion device and keeping <br />il in gaod working order, unless il is installed in the city ric�ht-of-�vay. <br />✓ If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to ir spect and maintain it on a regular basis. <br />(�I ant enclosiny all of �he necessary papenvork (use lhe yellow Rebate SubmiQal Checklist). <br />Select from the fallowing: <br />❑ �he conUactor idenlified do�vnspouls or olher drainage Ilines lhal were conne�ted to my s��•�er <br />Iine (belween my house and the installed device) and removed, or rerouled them. <br />❑ To my knowledge, my property has no downspouts or other drainage connecled lo my sewer line <br />(between my house and the installed device) <br />[}� There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the inslalled device). I understand Ihat leaving lhese conneclions creales a risk of (looding <br />and I accepl that risk. <br />� �/�`J � <br />Signature - � ��� (� .� L� Date �'�- � i� � �J <br />� <br />