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� <br />Backwater Prevention Device f2ebate Program <br />Rebate Application Form <br />Properly Owner Name: ',- �•;\�.-- " :'� ,;. � .. <br />InstallalionAddress: �' � � �>-1-��� '.�'1��� <br />City: � - -� Stale: '."� <br />'�.. <br />Mailinr� qddress (ifdil/e�entJ: _. '> '- � L� �..� � <br />Cily: _•:: I i • , : i ', St2te: . ' • <br />Email: . . �� :1� . ���.,,, �., .�.�. : .. <br />, <br />Total Cost to Install Device (Irom conlraclorinvoice): 5_ <br />'''�� �,, <br />Zip: i:i �.`j _ — <br />Phone ( i„�� '>b i , i., , `; — <br />Please verify the following: <br />��I am the owner ot Ihe property where Ihe backwaler pievenlion device was installed. <br />�� I worked wilh the contractor lo delertnine the location for the backaiater orevention tlevice and <br />imdersland thal Ihe decisian regardinp Ihr. localion of the device was mine. <br />�]� My contracfor inslructed me how to access, inspecl, and mainlain lhe device. <br />0 I undr,rst�nd Ihal I am responsible for mainlaining the Uackwaler prevention tlevice anA keeping <br />il in good workiny order, uNess it is installed m the aly right-o(-way <br />�� II I sell my property, I will make poleNlal buyr.rs aware o( the hackwater prevention device and <br />Ihe neeci to inspect and ma�nlain it on a re�ular basis. <br />[� I am enclosin� all o( the necessary papenvorY. (iisr. Ihe ycllavi Rebate SubmiUal Checklist). <br />Select irom the follov+ing� <br />�,� The contraclor ir�entified dovmspouls or olher cliainai�e Ilinr.s Ihal werc connected to my sewer <br />line (betv�een my house and Ihe in,tallcJ device) and removed, or rerouted Ihem. <br />❑ To my nnowledye, tny property has no downspoul; oi oth�:r drainage connecled lo rny sa�ier line <br />(betwecn rny housc and Ihe inslalled device). <br />❑ There are downspmits or olhei clrainapr. linr.s connectr.d to i7ry sewer line (belwren rrry housr, <br />and Uie installeU device). I untleistand thal Ieaving ihese connections creatas a risk of 1looding <br />and I accepl lhat risk. <br />• � <br />i ` <br />Signafure '-- :. .l• .!:� �" ' Date 1 �' �.i ; � � <br />_ , , <br />