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�Backwater Prev�ntion Device Rebate Program <br /> Rebate Application Form <br /> Property Oviner Namo: Asscmblics of God Foundation___,____ <br /> Installation Address 2605 [iaker Avc <br /> i City:�icrett __ Slale: WA Zip:98201 <br /> Meiling Address(d ddlerenry� 1661 N Baonville Ave STE E __ <br /> I City. Sorineficld Staln: MO Zip:55803 <br /> � <br /> i Email:,robertbC�iohnlscotLcom _.__ Phone: (425) 20b 221 ___ <br /> Total Cosl to Install Device(from cont�cfor invoiceJ.V�2 4R9.76 '� <br /> Pleaseverifythe(ollowing: Qlt ('t+ �p.y p/Operf.� cw�r .�Q,qpi►.7L fi+reyk 11fH1S <br /> � J <br /> ([J I am the owner o(tho proparty whare Ihe hackwater preve.iiion device was instalieA. T�1ou« �µr <br /> ��] I worked wilh the cont�aclor to determine Ihe location for Ihe backwater prevention devico and '(�—kl <br /> understand lhat Ihe decislon regarding the loplion of�he device was mine. I���� <br /> � My contractor insfrucced me how to access, insped,and mainlain Ihe device. ,q�2���s <br /> [�J I understand thal I am responsibie for maintaining Ihe backwater prr.��ntion dovice and keeping <br /> it in good working ordr.r, unless it is instaltr.d in Ihe city righto(-way. <br /> (J I(I sell my property, I will make potential buyers awarc of Uie bar.kwaler prevention dovi�n and <br /> !he neeA lo inspect md mainlain il on a regular basls. <br /> �J I am enclosing all oi 1he necessary papr.nvork(u,r_1he yellow Rebale Suhmittal Checkhsp <br /> Sclecthom thc followinp: <br /> [�J The coMrattor iAentified downspouts ur other dramage I!inex thal were connecled to my sewet <br /> line(bclwenn my house and the inslalled device) and removed, or reroutod them <br /> �{� To my knuwledge, rny ptt�perry has no AohnspouM or other drainage connecled to my sewer line <br /> (botween rny housr and ihe Instalted devi.e). <br /> 7� 1 here nre downspauls ar ulher drainape hnes connor.led tn my sower line(between my housc <br /> nnd the inslallod device). I unde�stand ihat leaving the;;e conneeiions creales a risk of Iluuding <br /> and I acr,ept tha�risk <br /> Sfgnafure� D�fe 71 Itil.(_) <br /> � )- I I <br />