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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />IProperty O�vner Name: NB �S /^�✓c��,s.�T <br />� Installation Address: �2/ _(.ic.n0 <br />City' �voi�i�- State: wA Zip: _Q$zc/ <br />� Wlailing Address (d diNerent): —_ <br />City: <br />Emad: <br />State: <br />Total Cost to Install Device (lrom confracfor invoice): S <br />1 <br />Please verify the following: <br />Phone: (�) SZz /�37 <br />j_' I am Ihe owner of the property where ihe backwater prevention device v�as installed. <br />[JY�worked wilh lhe conlraclor lo dMerrnine the localion for lhe bacl.�•�ater prevention device and <br />understand that the decision regarding the localion of Ihe device was mine. <br />�itviy contractor instructed me how to access, ��spect, and maintain the device. <br />�I understand that I am responsible for maintaining the backv�ater prevenLon device and keeping <br />it in good working order, unless it is inslalled in lhe ciry righl-of-way. <br />}r'If I seli my property, I wdl make potenlial buyers aware o( the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />�"f am enclosiny all of Ihe necessary papen•�ork luse the yellov: Rebale Submittal Checklist). <br />Select from fhe fellowing: <br />�The contraclor identi6ed do�anspouts or other drainage Ilines that vrere connected lo my sr.wer <br />line (behveen my house and ihe installed device) and removed, or rerouted lhem. <br />( � To my knowledge, my property has no dovmspouts or other drainage connected to my sewer line <br />(be�vicen my house and the inslalled device). <br />There are downspouis or o�her drainage lines connecled to my sevier hne (between my house <br />( md the installed device). I understand Ihal leaving ihese connections creates a �isk ot flooding <br />d I accepl that risk. <br />/ <br />/� �� <br />Signature ���� _ Datc 'v <br />