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"RP Backwater Prevention Device Rebate, Program <br /> . Rebate Application For <br /> Property Owner Name P(Y ' (Si <br /> alk <br /> Installation Address: r <br /> A e-L0 <br /> City: 7/ State: Zip: <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> Email: „Phone:( <br /> P4 3 <br /> Total Cost to install Device(from contractor invoice): <br /> - 1 <br /> Please verify the foliowingf <br /> be I:am the owner of the property where the backwater prevention devicewas installed: <br /> RI 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 /> tsk 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 /> ,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 needd,to inspect and maintain it on a regular basis. <br /> iihr I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checkl' ). 0,1 tie <br /> -'sect from the following: * <SNel <br /> 0 The contractor identified downspouts or other drainage Hines that were connected to my se =r 911 <br /> i' a(between my house and the installed device)and removed,or rerouted them. <br /> To my knowledge,my property has no downspouts or other drainage connectedto 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 <br />