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�� Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Property O��mer Name: _���KC y _ �Oh�✓1 � <br /> Installation Address _�L��_��C �iitl� /�(.(.e _ � <br /> CiIY' �✓��r''.��-- -State: W.G _Zip�����_— <br /> tvtailing Address(i(dil/erent): _ _ <br /> Cily: Slale: Zip: <br /> Email: _ Phone: ( ) <br /> I Tolal Cos[to Install Devlce (fran contractorinvoice): 5 2 S�a.� <br /> i —* -- <br /> Please vcrify the following: <br /> � I am the owner o(the pruperty �vhere the backwater prevenhon devic^u-as installed <br /> �vorked e�ifh the contractor lo delermine the IocaLon for the back�timter prevenlion device and <br /> imderstand thal the decision regarding the location of the device�vas mine. <br /> �y conUaclor inslructed me how to access, inspecl, and mamtain tl-�e device. <br /> , I understand that I am responsible for maintaining the backtivater prevenUon device and keeping <br /> it in c�ood working urder, unless il is inslalled in the city right-of-way. <br /> � f I sell my proper�y, I �vill make pctential buyers a�•�are o(the backtivater prevent�an device and <br /> ihe need to inspect and maintain it on a regular basis. <br /> ��am enclosing all of the necessary papenvork (use Ihe yellow Rebale Submitlal Checklisl). <br /> Sclect from thc following: <br /> �he contraclor idenhGed doemspouls or other drainaye IGnes Ihat wern conneGed to my se�ver <br /> line (between my house and Ihe installed dcvice)and removed, ar rerouled them. <br /> �o my kno�v�edpe, my property has no downspouts or olher drainage connected to my se�ver line <br /> (betv�een my house and Ihr. installed device). <br /> i <br /> �7j There are dovrnspouts or olhcr drainage lines connecled lo my sewet line (belween my house <br /> and Ihe installed device). I undersland that leaving these connections creales a r�sk of Ilooding <br /> and I accept that risk. <br /> Signafure Date YJ ��� <br />