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C�� <br />u <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property O�vner Name: �n�l__�JR�l1L� <br />Ins�allation Address� ��2 -�i t�7J1/ a�)llT sr. <br />ciry: ��/E�(ZF_.—T State. l�A. Zip�Q��/ <br />Mailing Adtlress (il drHerentJ: Sf�M F <br />Ciry' <br />Email <br />State: <br />Phone: (,�G)6 G07- i2G�� <br />Total Cosl lo In,tall Device (lrom contractor invoiceJ. 5 Z S�O. "— <br />Plc�se verify the (ollowing: <br />� I am the o�aner of the property �vhere the backwaler prevention device v�as installed <br />� I worked with Ihe contractor to determine Ihe location for the bacic�ti�ater prevention device and <br />understand that Ihe decision regardinq the localion of lhe device was mine. <br />�, My contractor instructed me how lo access, inspecl, and maintain the device. <br />'�I I unAerstand that I am responsible for mainlaining the haclnvater prevenlion dewce and keeping <br />�el in good working order, unless .t is installed in Qie ciry right-oi-way. <br />� It I sell my property, I wlll make pe!Antial buyers aware of Ihe backwater prevention device and <br />the need tn insper.t and maintain it on a reaular basis. <br />N I am enclosing all oF ihe necessary papenvork (use the yellaw Rebale Submlltai Checklist). <br />_� <br />Select from the following: <br />� The conirador idenlified do�vnspouts or other drainage Ilines that �vere connected to my sewer <br />line (beRveen my house and thc inslalled devicc) anA removed, or rerou�ed lhem. <br />� 1"o my knowledge, nry property has no downspouts or olher drainage connected lo my sewer line <br />(behvecn my house anA the ins�alled device). <br />❑ There are do�vnspouts or olher drainage lines connected lo my sewer line (belwcen my house <br />antl lhe inslalled device). I under,�and that Ieaving these conneclions creales a nsk of Ilooding <br />and I accepl thal nsk. <br />Signaturc �Y� �,,,.� Dare o5•/.9• �?O/J <br />