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�Backwater Prevention Device Rebate Program <br /> Rekrate Application Form <br /> Property Owner Name� Chuck Steinbe�ger. <br /> Installatbn Address: 152A Rucker Ave _ <br /> City; Evcrett State: W/1 7.ip:98201 <br /> Meiling Address (if diflerent)? _ <br /> City: __ State: -__ Zip: <br /> Email: chucksteinhereer(alanLcom _F'hone: (425) 239-434G <br /> Total•Cost lo lnstall Deuice (lrom contractor invorce): $ <br /> Please verify the Foilowi�g: <br /> � I am•the owner cf the propeity where the ba�kweler prevention davice was installad. <br /> � I worked with ihe contractor to detertnine Ihz localion tor iho backwaler prevention�device and <br /> understand that the declsion regerding the location of the dovice wos mine. <br /> � My contractor Instructed me how lo aCcess, inspect,and maintain tfie device. <br /> [{] I undersland�thal.l am responsible for maintainin_y ihe backwaler prevenllon.device a�d keeping <br /> it in gnnA workinc�order, unlese il is installed in tho ciry righl-of way, <br /> � If 1 sell my property, I will make pofential buyers aware of tho beckwate�prevenlion device antl <br /> thc need to inspecl and mafniain it on a regular basis. <br /> �] I am encbsing all oi the necessary paperviork(use the yellow Rebate Suhmittal�Checklisi�. <br /> Select from the following: <br /> [� The coMraclor idr.nlified downspouls or other di�inaya Ilines ihat wcia connectea lo my se�ver <br /> line (behvecn my house and the installed devi<w) and removed,or rerouled them. <br /> ❑ io my knowledg�,my properly has no downspouts ur olher drainage connected to my sewer line <br /> (behvr.en my housa and the,lnslalled device). <br /> [J There are.downspouls or other drainage linos connected to my sewer Iine(betweun my nouse <br /> end lhe installed device). I widerstand that leaviny these connecliona creates a rfsk of fboding <br /> 2nd�l accept that risk. <br /> / 2 Z ?_ai .� <br /> Signa(ure �!/`�* _�+ Date� - - ' J <br />