Laserfiche WebLink
Backwater Prevention Device Rebate Prc,;�ram <br /> Rebate Application Form <br /> P operty Oamer Name: _�Q w R 2c1 qt Al EVA FRF�n1 f� <br /> Installation Address: �(o�9 M p�LE 5 (. <br /> c�iy: E ���r; State: wA • Zip:qs 'a2o 1 <br /> Ivlailing Address (ildiHerenQ: �05 app�(h.$1 � /�lE • _ <br /> City: gRLinIB�Ton1 State: u1�i . _ .Zip:g8a2�- SS`II <br /> Email: Phcne: (�l 1��2 30 3_� ._ i <br /> Total Cost lo Install Device (Irom contractor invoiceJ: 5_��yo.�'� � <br /> I <br /> Please verify the following: <br /> � am the o�vner of the property�vhere the backwaler prevention device was installed. <br /> � I �vorked with the contractor to delermine lhe loca�ion (or the backwater prevenlion device and <br /> understand that the decision regarding the location of the device was mine. <br /> [7f tvly contractor instrucled me how to access, inspect, and maintain the device. <br /> � understand that I am responsible for maintaining lhe backwater prevention device and keeping <br /> it in good working order, unless il is installed in lhe city ric�hl-o(-�vay. <br /> �f I sell my property, I �vill make potential buyers a�vare of lhe backwater pieverlion device and <br /> lhe need to inspect and maintain it on a regular basis. <br /> �am endosing ali of lhe necessary papenvork (use the yello�•�Rebate Submittal Checklist). <br /> Select from the following: <br /> ❑ The contraclor identified do�vnspouts or other drainage Ilines lh;�t�vere connec�ed to my sewer <br /> line (bebveen my house and the installed device) and removed, or rerouted them. <br /> �To my knowledge, my property has no downspo•�Is or other drainage ronnected to my sewer line <br /> (behveen my house and Ihe inslalied device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer Iine(6etween my house <br /> and ihe installed device). I understand ihat leaving these conneclions creales a risk o(iloodmg <br /> and I accept that risk. <br /> Signature l�o•-���� ��r�-,�.�g-- Da[e_1 2- -Z� -�Y <br />