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�� Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ov: ner Name: ,� o n C Sac{4 ; <br />Installation Address: 7"} 3 I (/i f.ti,,�, c, ft �— <br />City: ��e.7'�' � -- 5121e: W � <br />h�lailing Address (if dilferentJ: <br />Cily: <br />Email: <br />S�ale: <br />Total Cosl lo Install Device (Irorn contractorinvoice): $ <br />Phone:( <br />�a� <br />Please verify thc following: <br />[vj 1 am Ihe owner of ihe properly v✓here ihe backwaler prevention davice was installed. <br />�a�(vdorke�! tvith lhe conirador tn delermine Ihe localion for the bar.k�vater prevention device and <br />understand that Ihe decision «:garding ihe localion of Ihe device was mine. <br />�� My conlractor instructed me how lo access, inspect, and maintain the device. <br />��undersland that I am responsihlc for maintaining lhe backwaler prevenlion devicc and keeping <br />it in ��nod working order, unless it is insfalled in Ihe city nght-o(-way. <br />[�( I sell iny property, I will make polenlial hiryers aware of lhe backwater prevention devir,e ond <br />Ihe nced to inspec� and maintain il cn a regular hasis. <br />� I am enr.losing all of ihe necessary paperwork (use the yellow Rebate Submitlal Checklist). <br />Sr.lect from the (ollowing: <br />�_}'The r.ontractor idenlitied downspoul; or olher drainaye Ilines lhal vaere connecfed to my sewer <br />-. me (belween my house and the mstalled device) and rernoved, or rr.routed them <br />���]/T�o my kno�vledge, my propeny has no downspoids or olher drainage connec;ed �o my sewer hne <br />i�beiween my house and Ihr, inslalled devicc) <br />;�f il hae am downspouts or other drainage lines connected to my sewer line (between my house <br />,ind Ihn inslalled device). I understand Ihat Ieaving Ihese cnnnections creales a risk of floodinq <br />and I ar.cep� Ihnt risk. <br />' /�� �// <br />' �/' � �_- .�� 5 <br />C%= (!����atc <br />