2306 PINE ST 2022-05-04 - Laserfiche WebLink

�_t_.� � _� ----- -- — --- ----�----- --- – - - - Backwater Prevention Device Rebate Program Rebate Application Form Property O�vner Name: . L�onrq 2D IU �oc�!-d nl InstallationAddress� a,3Q6—�•ve sr City: EU�/1E�r'- _ State: �i✓�Q Zip: 98�� 7 Mailing Address(if diKerenc): + Cily: State: Zip: Email: Phone: ( ) Total Cost to Instail Device (lrom contracforinvoice): S �C�,�� Please verify the following: � I am the o�vner of the property�vhere the backwater prevention device was installed. � I worked v�ilh the conlractor lo determine the location(or the backwater prevention device and understand that the decision regarding the location of the device was mine. ❑ My contractor instructed me how to access, inspect, and maintain the device. � I understand Ihal I am responsible for mainlaining the backwater prevention device and keeping it in good workinc� order, unless il is installed in the city right-of-way. � II I sell.my propeAy, I�vill make potenlial buyers aware of the backwater preve-ntion device and the need to inspect and mainlain it on a regular basis. ❑ I am endosing all of Ihe necessary papenvork (use the yellow Rebate Submittal Check6st). Select from the following: � The contractor identified do�vnspouls or other drainage Ilines that were connecled to my sewer line(behveen my house and'lhe installed device) and removed, or rerouted them. � To my knowledge, my property has no downspouts or other drainage connecled to my sewer line (between•my house and the installed device). ❑ There are downspouts or olher drainage lines connected to my sewer line (between my house and the installed device). I understand that leaving these connections creates a risk of flooding and I accept that risk. Signature ��=- � 1� ��-n Date 3��J l.i