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�, Backwater Prevention De�ice Rebate Program <br /> �w�, Rebate Application Form <br /> .�,«., <br /> ----- -- __ _ - - - -- _ <br /> Property Owner Name �Lsr,,,� �/�i.(� <br /> iInstallahnnAddress: _��Z ��vt�'r�__�l�'�__— -- � <br /> � City. Everett State W/1---__-Z�p 98201__----- .-_---- � <br /> I <br /> MaiGng Address (d diHerenf) __ ______—____ <br /> CitY - > State __. -- Z�pt------------ — <br /> Cmail _ �C '- Gll v 5 y� IY�!!!�� G�une (c{25l �l�f-SL5 ? — - <br /> I <br /> � Total Cost lo Instail Device (Irom confracfor nvoice) $ .�, YuZ y� <br /> � <br /> Please verify the following: <br /> (� I am the owner of Ihe property where Ihe backwator prevenhon device was mstalled. <br /> f{] I woiked with Ihe conVactor to determine the localion for tho backwaler prevenlion device and <br /> undersland thal lhe decision regard�nq Ihe loc�tion nl the dev�ce was mine <br /> �J Pdy contrador mstrucled me how to access, inspect, and mainlain the dewce <br /> ;�) I understand Ihat 1 am responeible for maintaininp the backwater prevention device and kaaping <br /> d In yood working ordcr, unless A is installed In the cily right-oGway <br /> [{] If I sell my property, I wdl make potenlial buyers aware o1 the batkweter prevention device and <br /> Ihc necd'o inspecl Hnd mainlain il a� a rnguler hesis <br /> (�] I am enclosing all of the necessary paperv+ork(use Ihe yellow Rebato Submittal ChecklisQ <br /> Selact from the following: <br /> �_] The contraao� identified downspouts or other drainage Ilmes that ware connected lo my sewe� <br /> hnr, (hetween my houso and Ihe mslalled device) antl removed, or rerouteA them <br /> �I'o my knuwledye, my property has no downspo�ts nr othur drainage cunnected lo nry suwer 6ne <br /> Ibehveen my house and the installed dewce) <br /> � There are down,pouls ur oQticr drauiayc lines wnnected to my sewcr linc (beM�ecn my housc <br /> ond the �nsta�led device) I underetand 1ha1 �eawng these connections creates a risk ol flooding <br /> and I accept that nsk. <br /> L � 7/ r5 <br /> SignatwA �" � Date " � " <br /> ,i <br /> C. <br />