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� <br /> i <br /> � <br /> �^� Backwater Pre�►ention Device Rebate Program ! <br /> Rebate Application Form 1 <br /> 1 <br /> _ <br /> _ � <br /> Property Owner Name: Tz��c.� L,�;,ea i <br /> InstallationAddress: �=�3z h_uc.k.c� nJ<--.-�ue � <br /> City ���eac-r Slale: Wa Zip: 9'v'�u� ' <br /> i <br /> � <br /> Mailing Address(il dilferenlJ: i <br /> City: Stale: Zip: <br /> Email: �����.�.f, '���i�-� LdG�n�m� . iu�� Phone: (4L5� 9:t �'���t4, ' <br /> � <br /> 1'otal Cost to Inslall Device (from contraclor invoice): $ , <br /> ; <br /> -- — — — � <br /> Please vcrify the following: j <br /> �i I am�he ovmer of the property where the backwater prevenfion device was installed. I <br /> � I worked wilh the contractor to determine the location for the backwater prevention device and � <br /> understand�hal the decisior.regarding Ihe location o(lhe device was mine. � <br /> P r��y contractor instruc�ed me how to access, inspect, and mainlain the device � <br /> Vj 1 understand thal I am responsihle for maintaining the backwater prevenlion device and keeping ' <br /> it in good workiny order, unless it is instailed in ihe city right-of-way. � <br /> � If I sell my properly, I will make polenlial buyers aw�ue of the backwater prevenlion device and I <br /> lhc need lo inspecl and mainlain it on a rec�ular basis. ' <br /> i <br /> [] I am enclosing all of thr. necessaiy papenvork (use lhc yelluv� Reba�e Subnutlal Checklisq. + <br /> Sclect from the following: i <br /> r] l he conlraclor idenli�ied downspouts or olher droina�e Ilines ihat were r.onnecled to my sewer � <br /> line (betwcen rny house and the inslallr.d device)�nd removed, or reroutr.d them � <br /> � To my knowled�e, my property has no downspouts or alher drnimge connecled to my sewer line <br /> (between rny house and thr inslal�ed device). I <br /> � J There are downspouls ui oRier drainage lines connected to my sewer line (beltveen my houso i <br /> and Ihe inslalled devic��) I undcrs�and lhal leavinc� Ihesc conneclions r.reatcs a risk of flrodinc� <br /> and I accepl Ihal iisk. <br /> 1 <br /> Signafurc �� `�� ^—`.— Datc •.��„-� ���,--,�.���-> �� <br /> � <br /> � <br /> , <br /> � <br />