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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: <br /> Installation Address: <br /> r � <br /> �, City: 'f State: Zip-18 <br /> I Mailing Address (if different): <br /> -C State:C State: 1�` _Zip: -� <br /> 3 City. <br /> � <br /> .a(� 1 'IC�- ( ar�' ;' O '12-2(I (p <br /> : .. <br /> Email: Phone:{�� <br /> Total Cost to Install Device (from contractor invoice): $ <br /> Please verify the following: <br /> I am the owner of the property where the backwater prevention device was installed. £� <br /> 1 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 /> l <br /> ...My contractor instructed me how to access, inspect,and maintain the device, I <br /> 1 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 /> 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 /> 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 Mines 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 Date ' ? E <br /> R <br /> 3 <br /> �- <br /> r _ M. <br /> �� M : Y_ <br />