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3 <br /> a <br /> c ater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: , c-. <br /> Installation Address: `~ � � .. Yf <br /> City: ,V- ` M State: LUH7 Zip: Cf <br /> Mailing Address (if different): <br /> I <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> t <br /> Total Cost to Install Device (from contractor invoice): $ <br /> Please verify the following: <br /> am the owner of the property where the backwater prevention device was installed. <br /> [i 41worked 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 /> Nlgy�contractor instructed me how to access, inspect, and maintain the device. <br /> 1 understand that I am responsible for maintaining the backwater prevention device and keeping i <br /> it in good working order, unless it is installed in the city right-of-way. <br /> 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 /> 1 am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> '-01 i <br /> Select from the following: <br /> he contractor identified downspouts or other drainage Ilines 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 /> t'1 <br /> Signature Date <br /> i <br /> } <br />