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�j Backwater Prevention Device Rebate Program <br /> �^�F,.,. Rebate Application Form <br /> M�-"' <br /> \ <br /> Property Owner Name: ���//Lf l��.S�LL <br /> Installation Address: ��O 0 a ��Gf��� �j/�lV UL <br /> City: �1���.�T]r State: !/V /4'- Zip: / ���� <br /> Mailing Address(il diHerent): s/�i9J C !`?'.S f�"80([C <br /> City: State' Zip: <br /> Email: Phone: ( ) <br /> Total Cost lo Install Device (Irom conlractor invoice): 5 ��S O � � �� <br /> Please verify the foliowing: <br /> �(] I am the owner of the property where lhe backwater prevention device was installed. <br /> � I worked wilh lhe contractor lo determine the localion for ihe backwater preventi..n device and <br /> understand lhat the decision reyarding the location oI the device was mine. <br /> � My contractor instrucled me how lo access, inspecl, and maintain the device. <br /> [� I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the cily righl-of-way. <br /> � If I sell my property, I will make polenlial buyers aware o(the backwater prevention device and <br /> lhe need to icspect and mainlain it on a regular basis. <br /> � I am enclosi�g�all of ihe necessary papervvork (use lhe yellow Rebate Submittal Checklist) <br /> Select from the following: <br /> 7 � The conlraclor identified downspouls or other drainage Ilines that were connecled to my sewer <br /> ' line (between my house and lhe installed device)and removed, or rerouted them. <br /> 7 � To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> ' (between my house and the inslalled duvice). <br /> � ❑ 7here are downspouts or other drainage lines connected to my sewer line (belween my house <br /> � and the installed device). I understand that leaving these connedions creates a risk of flooding <br /> and I accept that risk. <br /> Sig��ature jv ���Dafe /'�0 �6 <br />