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�,�}� Backwater Prevention Device Rebate Program <br /> �w� Rebate Application Form <br /> Property Ovmer Name: Vt'�"1't'ey `/�'� � V�� `� <br /> I Inslallation Address, �f���1��✓ �UG r' <br /> ICity f,V�✓t� Statc: (NVT' ZP�LU_� <br /> IMailing AdArzss(il drflerenl): <br /> Ciy: Staie: Zip <br /> iEmail ('�nC���YfMUY✓�3� 11o�Gi����hone: (J�'1 �J ��� <br /> ' Total Cost to Install Device(Irom contractor invace): 5_����� <br /> Please veriry the following: <br /> �am Ihe ow�er of 1he property where the backwaler preve�tion device was installed <br /> �worked with lhe conlractor to determine the ioca7ion ior the backwater prevent�on device and <br /> undersland lhat 1he decision regarding the IocaGon of the device was mine <br /> �My contractor instructed me hovr to access, irspect. snd maint�in ihe device. <br /> �I understand that I am responsible for maintaining the backwaler prevention device and keeping <br /> it in good working order, unless i1 is ins�alled in lhe clq�riaht-ot•way. <br /> ,� If I seil my property, I�vili make potential buyers awarc oi Ihe bacicwaler prevention devlce and <br /> �he need to inspecl and maintain it on a regular basis. <br /> am encbsing all of the necessary papenvork(use the yello�v Rebate S�bmittal Checklisq. <br /> Select irom the following: <br /> ❑ The coNraclor idenlified downspouls or other drainage Ilines thal were connected to my sewer <br /> Iine (between my house and the inslalled device)and removed,or rerouted them. <br /> � To my knowletlge, my property has no downspouts or other drinage connecfed to my sewer line <br /> (betwee�my house and lhe installed device). <br /> ❑ There are downspouts or other drainage hnes connected ro my sewer line(behveen my house <br /> antl�he mslailed device). 1 understand ihat teawng t�ese connec:ions creates a nsk ot flooding <br /> and I accept that risk. <br /> Ir� 3 '3�' 1� <br /> Signafu�e Date <br />