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Backwater Prevention Device Rebate Program <br />d Rebate Application Form <br />Property Owner Name: k I Lxunf <br />Installation Address: <br />)(2 Z <br />6s CLr d <br />'4VL <br />City: F.1'4/-e f'i <br />State: <br />WA <br />Zip: W7,01- /5017 <br />Mailing Address (itdilferent): <br />City: State: Zip: <br />Emali'_IcQlr/ , t/uc`U.d e c i''ti� r%Cllw„ Phonne:(10 )6L • (?`iS <br />Total Cost to Install Device (from contractor invoice): $ 2 ZQ q f -f-CLk <br />Please verify the following: <br />N I am the owner of the properly where the backwater prevention device was installed. <br />Q I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />dMy contractor instructed me how to access, inspect, and maintain the device. <br />I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless It is installed in the city 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 it on a regular basis. <br />4 1 am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist <br />Select from the following: <br />j The contractor idenliLed downspouts or other drainage (lines that were connected to my sewer <br />line (between my house and the 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 downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature Date � <br />