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�\���Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: Scott Larson <br />Installation Address: 811 Colbv Ave <br />City: Everett State: WA Zip:98201 <br />Mailing Address (rfdi(lsrenf): <br />Cily: State: Zip: <br />Email: Phone: (425) 315-5821 <br />Total Cost to Install Device (from contractorinvoiceJ: 5 <br />Piease verify the following: <br />j,7 I am the owner of the property where the baCkwater prevention devi�e was installed. <br />[{] I worked with lhe contractor to determi�e the Iocation for ihe backwater p�ave�tion device and <br />understand that the decision regarding the location of the device tivas mine. <br />0 My conUactar instructed me how lo access, inspect, and maintain lha device. <br />� I understand ihat I am responslble for mainteining Ihe backweter preve�tion device and keeping <br />it in good worki�g order, unless it is instailed ir the clty right•oi-way. <br />0 If I sell my property, I will make polentiai buyers aware ot the backwaler prevention devica and <br />lhe need lo inspect and maintain it on a regular basis. <br />0! am enclosing all o( the necessary paperwork (use the ��eticvr Rebale Submittal Checklist). <br />Select fram the following: <br />❑ The contraclor idenlified downspouls or other drainage Ilinos thal vrare connecled to my sewer <br />line (betwaen my house ond the installed device) and removed, or reroutod them. <br />(] To my knowledge, my property has no downspouls or olher drainage connocted to my sewer line <br />(behveen my house and the installed device). <br />❑ Thera are downspouts or other drainage lines connected lo my sewer lino (betvrean my house <br />and t11e inslalled devico). I understsnd that leaving these cunnectlons Creates o risk oE flooding <br />and I accept Ihet risk. <br />� 1 l <br />signaturo � / ��' "' Date �J�^ Li ^ � <br />