Laserfiche WebLink
i <br /> � <br /> ; <br /> ; <br /> � Backwater Prevention Device Rebate Program { <br /> Rebate Application Form <br /> _ I <br /> � � <br /> Proocrty Owner Name ��jesh Suran2 � <br /> Installalion Address _?326 Pine St � <br /> Ci1y: Everett Statc. WA 2ip: 98201 i <br /> i <br /> Mailing Address(AUrllerent): 4607 1441h PI SE <br /> City Snohomish State ,yyA Zip. 98296 ; <br /> Email:�jp����IIang gmail_com Phone (20Q 9155709 � � <br /> � <br /> � Tofal Cost to lnsla�l Device(trom contractor invoice�: g 2�5��'�d � <br /> I � <br /> ----' -' -- f <br /> Pleasc verify the following: ' <br /> � I am tne owner o`the property where the backwater prevention tlevice vras instalied. <br /> i <br /> � I werked viith the contraclor to determine the location for the back�vater prevention device and <br /> undersfard that the decision regarding the locatlon of the device was mine. <br /> �c] h4/contractor instructed me how to a�cess, inspect, and ma�ntain the deviCe <br /> '� 1 understand that I am responsible tor maintaining Ihe backwater prevention device and keeping • <br /> it in good workmg order, uniess it is installed in the city nghtof-�.vay ; <br /> [ If i sell my property, 1 will make oo;entiat buy�ers aware of the backwater prevent�on oevice and <br /> the need lo inspect and mmntain d on a regular basis <br /> ! <br /> �k) I am endosing ali of the necessary paperv;ork(use t�e yello�:� Rebate Submitt�l Checktist) <br /> Select trom the lollowing: <br /> [ � The con�rac,or identified do�•:nspouts or olher drainage Ilines that were cannected to my se�ver � <br /> line (behveen my house and the installed dewce) and removed, or rewuted them. + <br /> i <br /> ;XJ To my knowtedge, my property has no downspouts or other drainage connected to my setiver hne � <br /> (behveen my house and the inslalled device) • <br /> [� There are downspouts or other drainage Imes connecled to my se�ver hne (behveen my house ! <br /> and the installed device). I understand lhat leawng these cennections creates a nsk ot flooding <br /> and I accent ihal risk <br /> i <br /> I <br /> i <br /> Signatuio 4y� G�_�_ Dafe U= I � . 2�-�1 S � <br /> _�� <br />