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�Backwater Prevention Device Rebate Program <br />Q, Rebate Application Form <br />Properry Owncr Name: M EuS-_h Z�fV��i EN�S �-LC— <br />Ins�allation Adtlress: 3817 __�i��T +1 uE+.� u_E <br />City. �V � Slate: w� Zip: `l�a•� � <br />Mai{ing A�Jdress (if dilfeient): Slp ��/ `t 5����LE <br />City: TLL�.q-�ap _ State: W R Zip: 98a7�—�,80� <br />Email: �t�n�-,�5wih����m3h.r�M Phone:(3�)6,5S-81L�'l' _ <br />ITotal Cost to Install Device (/rom confrar,tor invoice): 5 _�', So� �� <br />�-- -- — -- -- - - - <br />Please verify the followiny: <br />�J I am the o�.vner oF lhe property �vhere the backwater prevenlion device edas installed. <br />� I worked with the contraclor to determine lhe tocation for the backwalEr prevention device and <br />� understand thal the decision regarding the location af the device was mine. <br />� tvly contractor inslructed me how lo access, inspect, and maintain ihe device <br />j� I understand that I am resporsibte for maintaining the backwater prevenlion device and keepmg <br />it in gcod working order, unless it is installed in the city right of-way. <br />[�� If I sell my propedy, I will make polentiai buyers a�vare oi lhe backwater prevenlion device and <br />�` lhe need lo inspect and maintain it on 2 regular basis. <br />� I am enclosing all o( the necessary papenvork (use the yellow Rebate Submiital Checklist). <br />Select (rom thc following: <br />[j The contrector identihed do�vnspouts or other drainaye ihnes lhat tvere connecled to my sewer <br />line (bet�veen nry house and Ihe inslalled devlc�) and rernoved, or reruuted them. <br />�To my knowiedge, my property has no downspouls or other drainage connecled to my sev�e� hne <br />between my house and the installed device). <br />❑ There are downspouts or other drainaye lines connected to my sewer line (behveen r�y house <br />and ihe installed device). I understan�! Ihat Ieaving these r,onnecLons creales a risk o( tlo,�ding <br />and I accept that risk. <br />/"r� ; <br />. ; , � ��, - ,/,_ <br />Signature---.i, �%�✓� _ Date _ � �: ;-- <br />_ -- � <br />