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#01111t, Backwater Prevention Device Rebate Program <br /> trle Rebate Application Form <br /> Property Owner Name: 1 0 `t) to“tt '7' <br /> i <br /> Installation Address: l /7 1 4k <br /> City: (i-,.. Stater Li/ Zip: 9r2-0 1 <br /> Mailing Address (if different): <br /> City: State: Zip: <br /> Email: Phone: (Lf 2‘229 <br /> . <br /> Total Cost to Install Device (from contractor invoice): $ t 5--c ,....----------- <br /> Please <br /> ' ,Please verify the following: <br /> I a.• the owner of the property where the backwater prevention device was installed. <br /> fl I worked with the contractor to determine the loca ion for the backwater prevention device and <br /> understand that the decision regarding the locatioi of the device was mine. <br /> ( My contractor instructed me how to access, inspe t, and maintain the device. <br /> '' f 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 /> ` If I sell my property, I will make potential buyers a ware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> "°-lIJ I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> Ill/The contractor identified downspouts or other drainage (lines that were connected to my sewer <br /> lin (between my house and the installed device) and removed, or rerouted them. <br /> \rjrj my knowledge, my property has no downspou:s or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> There are downspouts or other drainage lines cor nected 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 /> r <br /> Signature ' Uate <br /> k <br /> 1 <br />