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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: EDYTHE PAVISH I <br /> � 1322GRANDAVENUE I <br /> Instailation AddfE55: EVENETT,WASHINGTON 98201 <br /> City: State: Zip'_ <br /> Mailing Address (if diNerent): <br /> City: State: Zip' <br /> Email: Phone: ( )__ <br /> Total Cost �o Install Device (from contractorinvoice): $ <br /> Please verify the fullowing: <br /> ,[?-i am the owner of the property evhere the backwater prevention device was installed. <br /> .!]" I worked wilh the contractor lo determine the localion for the back�vater prevention device and <br /> undersland that the decision regarding the location of the device was mine. <br /> .] My contractor instructed me how lo access, inspect, and maintain the device. <br /> -� I understand that I am responsible for maintaining the backwaler prevention device and keeping <br /> it in good working order, uniess it is installed in the city right-of-way. <br /> � I(I seli my properly, I will make potenlial buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a reguiar basis. <br /> .�] I am enclosing all of the necessary paperwork (use the yetlow Rebate Submittal Checklist). <br /> Select fram the following: <br /> ❑ The coMractor identified dovrnspouts or other drainage Ilines lhat were connected to my sewer <br /> li (between my house and the installed device) and removed, or rerouled lhem. <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 o other drainage lines connecled lo my sewer line(between my house <br /> and Ihe inslalled device). I understand lhal leaving these connections creates a risk ot Oooding <br /> and I accept Ihat risk. <br /> �� <br /> i�,. ' I <br /> giy�� '-�,/�%'// ,�p��� Date � - 2� �� `� <br />