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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: "f 7 4moi, j` r 7i't.C. �G r 0 <br /> --T <br /> Installation Address: <br /> City: V 'ay-� State: (- Zip: <br /> Mailing Address (if different): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (from contractor invoice):$ ='PP �7�- s � <br /> Ple#se verify the following: <br /> Vv <br /> `!am the owner of the property where the backwater prevention device was installed <br /> ['`l worked with the contractor to determine the location for the backwater'prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> [D-`6y contractor instructed me how to access, inspect, and maintain the device. i <br /> ©' I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> 0—If I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> [ ` I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> The contractor identified downspouts or other drainage (lines that were connected to my sewer <br /> line(between my house and the installed device) and removed, or rerouted them, <br /> To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed 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 /> Signature �� r' Date / r / <br />