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4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: Kristine Washburn _ <br />Installation Address: 1808 Lombard Ave <br />City: Everett State: WA _Zip: 98201 !! <br />Mailing Address (ifdiN.erent):. _ <br />City: State: Zip: <br />Email. kcwashburn gmail.com Phone: (206) 523-62.54 <br />Total Cost to Install Device (from contmclor invoice): $ 2,484.76 <br />Please verify the following: <br />,gj I am the owner of the property where the backwater prevention device was installed. <br />I worked with the contractor to determine the Iocallon for the backwater prevention device and <br />understand that the decision regarding the tocalion of the device was mine. <br />My contractor instructed me how to access, inspect, and mainta'n the device. <br />© I understand that I am resporiaible 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 />�i If I sell my property. I will make pulential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />[{] I am enclosing all of the necessary paperwork (use the yeliow Rebate Submittal Checklist). <br />Select from the following: <br />Q The contractor identified downspouts or other drainage Ilines that were connected to my sower <br />line (between my house and lire 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 />0 There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). 1 understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />1 <br />Slgnamre /LG.T � � �/1��Date <br />