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Backwater Preveintion Device Rebate Program <br /> ,it , �_ Rebate Application Form <br /> Property Owner Name: ,3' i <br /> -. ,A , <br /> Installation Address: '- <br /> City: er, State: 14At Zip: <br /> Mailing Address(if different):; <br /> City: State: Zip . <br /> 1 <br /> e <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 /> I 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 /> NtSk\My contractor instructed me how to access,inspect,and Maintain the device. <br /> I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> 't 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 /> VI I =m enclosing.all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> ct from the following: <br /> [] T e-contractor Identified downspouts or other drainage Mines that were connected to my sewer <br /> ne(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 /> 0 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 /> P , <br /> SignatureDate <br />