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�^%��Backwater Prevention Device Rebate Program <br />L�,,, Rebate Application Form <br />Properly Owner Nama �ifis�__E,�-�r'�/z¢�r¢�-i - �¢u%i.r F. /-L��� '-er•E _ <br />Inslallalion Address: �j �% ���6i.ci/.s�, i3'vt <br />City: y_E,i-�% State: l��• Zip:�2O/ <br />R4ailing Address (if dllferenQ: <br />Ciry: <br />Slate: <br />Email: __ Phone: ( ) ____ _ <br />T�tal Cosl to Inslall Device ((rom r.onfrar.torinvoice): $ 7��'�C� � <br />Please verify the following: <br />�7J I am the owner of the property where the back�vater prevention device was ins�alled. <br />;j� I worked viilh lhe contraclor to detennine lhe location for Ihe backwaler prevention r'evice and <br />undersland lhat llie decision re�arding thr, localion ci the device was mine. <br />�J My coNractor insirucled me how �o access, inspect, and maintain the device. <br />6Q I undersland that I am responsible for maintaining Ihe backwater prevention dewce and keeping <br />it in good working order, unless il is installed in ihe city riyht-ot-way. <br />� If I sell my property, I will make polential buyers aware of lhe backwaler preventic i device and <br />the nr.ed lo inspecl and mointain it on a regular basis. <br />� I am enclosing 8II Oi iI18 I1CCCti5:lfY j1�j1F'RNMB �lISP. (I1P. yP,IIOVJ RCI7;1(C SUhfT11��8I CIICCRI15(�. <br />Se!ect from tlie following: <br />j J The contrac�nr iAenlilied dnvdnsprntls or other drainage Ilines thal �verr. conner.led lo nry sewer <br />r��lu c(belwcen my house and the inslalled device) and removed, or rerouled lheni. <br />o my knnwledge, my praperly has no do�.nspouts or other drainage connected to my sewer line <br />(belween my housc and Ihe inslalled devico). <br />❑ T here are downspouts or other drainage lines conner.ted lo my sewer 6ne (between my house <br />and lhe inslalled device). I understand Ilial leaving Ihese conneclions creales a risk of Ilooding <br />and I accepl Ihat nsk. <br />Siynafure__ �st___p���-r Date �•i/J'f,_j' 1 / <br />� �v <br />