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�Backwater Prevention Device Rebate Program <br />Q, Rebate Application Form <br />Properiy Owier Name: <br />Installalion Address: 0471 � s.7� �� <br />City: �� State: _�,%�___ Zip <br />Mailing Address (if diflerent): <br />City: Slafe: <br />Email• � A'�,� {��$i�. C0�1�1 <br />Tot21 Cost lo Install Device (from conlraclorinvoice): i <br />Please verify the followino� <br />�IJ <br />Zip: <br />Phone: ( l�) �L —���� <br />��3�-�� <br />�� I am lhe owner of the property where the backwater prevention device was inslalled. <br />i <br />I worked wilh the contraclor to determine lhe localion for Ihe backwaler prevention device and . <br />understand thal the decision regarding the localion o( lhe device was mine. <br />I� My contractor inslruded me how lo access, inspect, and maintain �he device. <br />��L <br />I understand lhal I am responsible for maintaininy the backwater prevention device and keeping <br />il in good working order, unless il is installed in the city righl-of-way. <br />�If I sell my property, I will make potenlial buyers aware of Ihe backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />I am enclosing all of Ihe necessary papenvork (use the yellow Rebate Submittal Checklist). <br />Select (rom the following: <br />[� The r.onUactor idenlified downspouls or other drainage Ilines Ihat were connected lo my sewer <br />line (belween rny house and Ihe inslalled device) and removed, or rerouted them. <br />To my knowled�e, my property has no downspouts or olher drainage connected lo my sewer line <br />(belween my housr. and the installed devir.e). <br />[� There arc downspouls or olher drainage Ilnes connecled � sewrr �me (between my fwuse <br />and the inslalled device). I undersland that leaving these co.,nections r,reates a nsk of flooding <br />and I accepl lhal nsk. <br />Signature��f��a� �L� �' Date _ �V /� <br />� <br />