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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> �, � " � � �� <br /> Property Owner Name: (h _y�vw+ u"t <br /> Installation Address: � �7.`� ��� ��/e— _ <br /> City: Cvc.�rc.� Staie: WA Zip: ��?,6� <br /> Mailing Adoress(i(diHerentf: ' <br /> City: itate: Zip: <br /> Email:�r;� �e..�v an:w a� ��� • C_c�� Phone: (zW) a.95 --£1,`£UI <br /> Total Cost to Install Device (from contractorinvoice): $ o��!3 1� X <br /> Piease verify the following: <br /> � I am the owner of the property where the backwaler prevention device was installed. <br /> � I worked with the contrector to determine the location for the backwater prevention device and <br /> understand thal lhe decision regarding the iocation ot ihe device was mine. <br /> �r My contractor instructed me how to access, inspect, and maintain the device. <br /> � I undersland that I am responsible for maintaining the backwaler prevention device and keeping <br /> it in good working order, unless it is installed in the cily 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 il on a regular basis. - <br /> � I am�nclosing all•of the necessary paperv✓ork(use the yellow Rebate Submittal Checklisl). <br /> Select from the following: <br /> �D The contraclor idenlified downspouls or other drainage Ilines that were connected to my sewer 4 <br /> � line(between my house and lhe 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 /> ❑ There are downspouls or other drainage lines connecled to my sewer line(belween my house <br /> and the installed device). I undersland that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Signature, ��� �� Date 1�. ' � ^�lY <br />