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Backwater Prevention Device Rebate Program <br /> ����*� �����U~�����n Form <br /> Rebate Application <br /> Property Owner Nam <br /> Installation Address'. V <br /> State: zip: <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> Email: Phone: 104 <br /> Total Cost to Install Device (from contractor invoice): $ <br /> Please verify the following: <br /> rc3'� m thamvvnerofthe proper�vvherothe backma�er dev�evvaa�ota�d <br /> ��m�hed with the contractor todetermine the location for the backwater prevention device and <br /> the dmc��nregarding the hoomt�nofthe device vvosmine. <br /> �My contractor instructed me how to access, inspect, and maintain the device. <br /> understand that I am responsible for maintaining the backwater prevention device and keeping <br /> ~` it ood working order, unless itioinstalled inthe city ri0ht-of- vay. <br /> sell my property, I will make potential buyers aware nfthe backwater prevention device and <br /> to inspect and maintain it on a regular basis. <br /> enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> -��eUec��omm the following: <br /> The contractor identified downspouts or other drainage Hines that were connected to my sewer <br /> |hn ho dthe |n�oUoddeico) and rennoved. orrerouted #honm. <br /> I <br /> o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between myhouse and the installed davioa� <br /> �l <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 | accept that risk. <br /> Signatur 66 Date <br />