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Backwater Prevention Device Reba±e P�ogram <br /> Rebate Applicatian Form <br /> 0 `,, <br /> Property Owner Nam�. __�7Lt0-V [Sz'L-- r�S�-i �(1✓ <br /> Installation Address:�2 v��� � � _____ <br /> City:_�� 1 _ State: '^� � Zip: / J �- �� __ <br /> Mailing Address (il dillerent):_ __ _ <br /> City: _ State _Zip:. ___ <br /> EmaiC___ Phone: (�J—2��—�� 6 <br /> Total Cost to Install Device (lrom confracfor invoiceJ: $���� 3� ___ <br /> Please verify the following: <br /> [�am lhe owner of!he property where the backwater preventio-� device was instailed. <br /> [t�l worked with lhe contractor to delermine the localion for lhe ba�k,vater prevantion device and <br /> understand that the decision regarding th: '�cation of the device was mine. <br /> D�1Gly contraclor instructed me ho�v to access, inspect, and maintain the device. <br /> [�t understand that I am responsible (or mainlaining the bacicwaler prevention devir,e and keeping <br /> il in good working order, unless il is installed in lhe city right-of-way. <br /> [�ilfl sell my property, I �vill make potential buyers awarc of the backwater prevention device and <br /> �t e need lo insp�ct a7d maintain il on a regular basis. <br /> am enclosing all of lhe necessary paperv�ork(use ihe yellow Rebate Submittal Checklisl). <br /> Select from the following: <br /> ❑ The contractor identified downspouls or o�her drainage Ilines that were connected to my sewer <br /> line (between my house and lhe installed device) and removed, or rerouted them. <br /> o my kno�.vledge, my property has no downspouls or other drainage connected fo my sewer line <br /> (between my house and the i�stalled device). <br /> � There are downspouts or olher drainage lines connecled to my se�,ver li;ie (helween my house <br /> and the inslalled device). I understand lhat leaving these conneclions creates a risk of flooding <br /> and I accept lhat risk. <br /> '�j i <br /> Slgnafure_��_�,�!����— Date_ _ c-�_ZU�S <br /> J <br />��� <br />