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�Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />PropeAy Owner Name: Blake Scott <br />Installation Address 732 �olbv Ave <br />Cily: Everett State: WA Zip:98201 <br />Mailing Address pf diNerenf) <br />City: State: Zip. <br />Email: blakescott a vahoo.com Phone� (360) 927•3814 <br />Totai Cosl to Install Device ((rom contractor invoiceJ: 5 3.822.00 <br />Pleaee verify the fallowing: <br />Q I am the owner of the property where Ihe backwater prevention device was installed. <br />�] I worked with Ihe contraclor to delermine the localion for the backwater prevenlion device and <br />undersland that the decision regarding lhe lotalion of Iho device was mine <br />[{j hiy contractor inslructed me hoel to access, inspect, and mainlain the device. <br />[,] I understand tha� I am responsible for mainlaining lhe backwater prevention device and keeping <br />d in good working order, unless il is installed in lhe city nght-ol•way <br />[✓] If I sell my property. I will make polential buyers aware of the backvuater prevention device and <br />the necd to inspecl and maintain il on a regular basis <br />� i am enclosing all of the necessary papenvork (use the yollow Rebale Submiflal Checklist). <br />Select from the fallowing: <br />❑ The contractor idenlified downspouts or other dramage Ilines thal �vere connecled to my sewer <br />line (belween my house and the mstalled device) and removeJ, or rcrouled lhem. <br />❑ To my kno�vledge, my property has no downspouts or olher drainage connected to my sewer line <br />(beNreen my house anJ the installed davice). <br />Q✓ There are downspouts or other drainage lines connec�ed to my se�ver line (bertveen my house <br />and ll�e inslalled device). I undorsland thal leaving these connetlions creates a risk of floading <br />and I accepl that risk <br />Signaturc� � �; ,; ;% � �.� Date � /-/Z - /S <br />