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Backwater Prevention Device Rebate Program <br />Rebate �pplication Form <br />Property Owner Name: C�� `� �1 �-���� <br />Installat�on Address: 11 o`j Zt � S'�'- <br />City: ���•�" State: WP- Zip� i&Zii � ' <br />Mailing Address (i(di/(erent): 194c3 '�Z�..d P� uJ <br />�City: L���Ww�1 State: �..:P _Zip: q�Q�'�' <br />Email: �ina��ielne U���� . c�un Phone: (u6) q�-1-4�5% — <br />Total Cost lo install Device ((.vm contrac(or invoice)� � <br />Please verify the following: <br />� I am lhe ovmer of the properiy wnere the backwaler prevention device was installed. <br />�J I worked wilh the contractor to delermine the location for the backwater prevention device ar,d <br />understand that the decision regarding the location of the device was.mine. <br />� My contractor instructed me how to access, inspecl, and maintain the device. <br />� I understand that I am responsible for maintaining lhe backwaler prevention device and keeping <br />it in good working order, unless il is installed in the city right-of-way. <br />� If I sell my property, I will make potential buyers aware of the backwaler prevention device and <br />the need to inspect and maintain it on a regular besis. <br />'� I am enclosing all ot the necessary papenvork (use :he yeilow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The confractor idenlified downspouts or other drainage Ilines that wer�� connecled lo my sewer <br />line (hetween my house and the installed device) and removed, or rerouted tfiem. <br />��j To my knowledge, my property has no downspouts or.olher dreinage connecled to my sewer line <br />(belween my house and ihe inslalled device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />/��n/� �^�,,� <br />Signature / l 1'✓ 1%I' Date S•-\—IS_ <br />L� v <br />