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Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Property Owner Name: �O f N J�. A � �t.C�N <br /> Installalion Address: A`� c`7S` � ��o�n ^�'�e <br /> City: 1�1Q C�� State: W A Zip: � c�ZJ �� <br /> Mailing Address(if di((erent): �� A <br /> Ciry: State: Zip: <br /> Email: Phone: ( ) I <br /> Total Cost to Install Device (from contracforinvoice): S <br /> Piease verify the following: <br /> � I am lhe owner of the property where the bac4avater prevention device was installed. <br /> [rj/I worked wilh the contraclor lo determine the location for the backwaler prevention device and <br /> understand that the decision regarding the localion of Ihe devi:e was mine. <br /> �'My coniractor instructed me ho�v to access, inspect, and maintain lhe device. <br /> �I understand lhat I am responsible for maintairnng the backwaler ptevention device and keeping <br /> it in good working order, unless ii is installed in the city right•of•way. <br /> �f I sell my property, I will make polential buyers aware ot lhe backwater prevenlion device and <br /> the need to inspect and maintain it on a regular basis. <br /> �I am enclosing all ot lhe necessary paperwork(use the yellow Reba�e Su�millal Checklisl). <br /> Select from lhe following: <br /> ❑ The coNractor idenlified downspouts or olher drainage.11ines lhat were connected to my sewer _. <br /> line (belween my house aiid thc installed device) and removed, or rerouted lhem. <br /> �o my kno�vledge, my property has no downspouts or other drainage connected to my sewer line <br /> (belween my house and the installed device). <br /> ❑ There are downspouls or olher drainage lines connected lo my sewer line (behveen my house <br /> and the inslalled device). I understand lhat leaving Ihese connections creates a risk oF flooding <br /> and I accept thal risk. <br /> Signature ���� V�lt ��ss.�lDate � ` �4 ^ � S✓ <br /> J <br />