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Backwatar Prevention Device Rebate Program <br />Rebate Application Form <br />Thcu" rAc, n <br />Property Owner Name: TherrnarrGranbery <br />Installation Address: 3414 Oakes Ave _ <br />City: Everett _ State: WA Zip: 98201 <br />Mailing Address (if different): <br />City: <br />State: <br />Email: nancvboyerl3(ahotmail.com Phone: (425) 765.6204 <br />Total Cost to Install Device (frorn contractor invoice): $ 2,500.68 <br />Please verify the following: 7 <br />2 1 am the owner of the property where the backwater prevention device was installed. <br />lfi I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the declsion regarding the location of the device was mine. <br />[{] My 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, 1 will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />r 1 am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />�{] The contractor identified 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 />fL7' To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and th-. installed device). <br />n 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 />SignaturerITIC v ✓.t /�4L/ ' Date <br />\ 0 ✓�— <br />