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�,�}� Backwater Prevention Device Rebate Program <br /> �'�� Rebate Application Form <br /> ��"_�-- <br /> Property Owner Name: ���Tu 1SK V �t�'��l2ES � ItJG. <br /> Installation Address: __�'(�3'7� J�C(,i,�l� /�'V'[.►��E <br /> Cily: E�E�"TT State: w� Zip: 0�� <br /> Mailing Address(if dilferent): <br /> City: Stale: Zip: <br /> Email: Phone� ( ) <br /> Total Cosl t� Install Device (from contractor invoice): S <br /> Please verify the following: <br /> �am the o�vner of the property where ihe back�vater prevention device was inslalled. <br /> �nvorked with the conUaclor to determine the localion for the backwaler prevention device and <br /> undersland that the decision regarding !he localion of the device was mine. <br /> ��b y contraclor inslrucled me how to access, inspecl, and maintain the device. <br /> undersland that I am responsible for maintaining lhe backwater prevention device and keeping <br /> it.in good working order, unless it is installed in the city right-of-way. <br /> �I sell my property, I will make potential buyers aware of ihe backwater prevention device and . <br /> the need lo inspect and maintain it on a regular basis. <br /> �am enclosing all of Ihe necessary paperwork (use lhe yeliow Rebate Submiltal Checklist). <br /> Select from the following: <br /> ❑ The conlractor idenlified downspouts or other drainage Ilines that were connecled !o my sewer <br /> line (between my house and lhe inslalled device) and removed, or rerouled them. <br /> ❑ To my kno�vledge, my properly has no downspouls or other drainage conneGed to my sewer line <br /> �elween my housc and lhe inslalled device). <br /> here are downspouls or other drainage lines connected lo my sewer line(belween my house <br /> and the inslelled device). I understand that leavin,y these conneclions creales a risk of Oooding <br /> and I accept that risk. <br /> Signature ��� _Date 5 � �� <br />