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� • , � "�,�';k�"F »;: = rr�8=F�:; <br /> T.t ':,�� } �Tn.y� } � �' }b-l�� . ,4.��'ro�7'. .��. 1�'� " ��i . . <br /> �i �� i:L�C 5 .t . �'A •�'k� 4T • t . . . � . ' . . ' <br /> J � <br /> , 4 • <br /> ' .�� ',+� ^ y, '..`,. , �J ; ',' . , <br /> ' •�l �" �. �l �, 1 1l 1 • i <br /> Backwa�ter Pr�v�ntion Device Rebate Pr�ogra�n;� <br /> Reb�te Application Form '"' � . � <br /> � - . . . <br /> � PropeAyOwnerName: . N�rokn 'Fc+�.�4'e ' <br /> ; <br /> ' Installation Address: ' a�S03- P� � S�R�t <br /> � Ciry: ti�ecakt Stale: W A Zip: � q�'�'�� � <br /> Mailing Address (il diNerent): ���-�� ��`� �-u N=f fl3� - � <br /> f�' � <br /> , City: ��.<<c�ancX- Slale: W� Zip: ��3�` _ �: <br /> � <br /> i Email: �kccbSSc�ne:w2t ' Phone: (��c) '��Y- °w111 _ ', <br /> Total Cosl lo Install Device (Irom confractorinvoice): S �`���'g� <br /> Please verify the following: . <br /> , ��, . , , . , , , ;;.': ;-.�<. .:; :. <br /> 0 I am the owner of the property where th� .ackwater prevention device was'installed. <br /> �worked wilh lhe conVactor to determine the location for the backwaler prevePtioh device and <br /> , understand ltiat th2 decision regarding the locafion ot lhe device was mine". � <br /> 1 �M coptractor instructed me how to access,inspecl, and maintain the device. . <br /> � I understand that I am responsible for mainlaiaing the backwater p�evenlion,deviCe and keeping <br /> it i •good working order, unless it is inslalled in the ciry right•of-way. <br /> I kj If I seu my property, I will make polential buyers aware of the backwater prevention device�and ' � <br /> tlle need lo inspect and mainlain il on a re9ular basis. <br /> , ,�I am enclosing alt�O(Ihe necessary paperwork(use the yeliow Rebals Subi.iittal Checklist). <br /> � Select trom the following: <br /> , <br /> � � The coMractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> Ili e(helween my house and the installed device)and removed, or rerouted them. <br /> �o my knowledge, my property has no downspouts or other drainage connected lo my sewer line I <br /> (between my house and lhe instalied device). i <br /> � ❑ There are downspouts or other drainage lines conneGed lo my sewer lino(between mY house � <br /> � and lhe instailed device). I understand that leaving these wnnections creates a risk of flooding <br /> � and I accept thal risk. <br /> I � <br /> , Signature 1�, Date � <br /> i i <br /> i i <br /> � I <br />