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i <br /> I <br /> i <br /> ; <br /> Backwater Prevention Device Rebate Program ; <br /> Rebate Ap�lication Form . <br /> � <br /> Property0e+nerName: Donavan Rieger � <br /> InstallationAddress: 2229 Rockfeller Ave � <br /> �;N; Everett Stale:_��_Z�p. 9820] � <br /> Mailing Address (il diHerent): <br /> �{H; State: Zip� � <br /> Email: Phone: ( ) 4?S 23� Sti"�3 � <br /> � <br /> Total Cost to Instail Device ((rom contractorinvoiceJ: 5 ' <br /> i <br /> � <br /> I <br /> Please verify the following: � <br /> � I am the owner of the properiy where the backwater prevention device was installed. � <br /> ❑ I worked•Hdh the contractor to determine tha location for the backwaler prevention device and � <br /> understand that the decision regarding the location of the device was mine. <br /> ❑ My contractor instrucled me how to accass, inspect, and maintain the device. ! <br /> { <br /> ❑ I understand thal I am responsible for maintaining the backwater prevention device and keeping � <br /> it in good working order, unless it is installed in the ciry right•of-wey. � <br /> ❑ If I sell my property, I will make potential buyers aware of the backwater prevention device and i <br /> Ihe need to inspect and maintain it on a regular basis. i <br /> ❑ I am enclosing all of the necessary paperwork(use Ihe yellow Rebate Submittal Checklist). , <br /> Select from the Tollowing: � <br /> ❑ The contraclor identified downspouts or other drainagu Ilines that were connected to my sewer � <br /> line (between my house and the installed device) and removed, or rerouted them. <br /> ❑ To my knowiedge, my property has no downspouls or other drainage connected to my sewer Ilne <br /> (between my house and the instalied device). <br /> [] There are downspouts or other drainage Iines connected to rc,y sewer line(between my house ; <br /> and the installed device). I understand Ihat leaving these connections creales a risk of flooding � <br /> and I accept that risk. � <br /> i <br /> 04 /15 /2014 � <br /> Signature—�7nnnr�cr Date i <br /> ; <br /> i <br /> i <br />