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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: �6�AA� �. GARREr <br /> I Inslallation Address: Z�O ,� �dcl�E�' /�vE, <br /> I City: EVER�7T s�ate: WA. zip: 9�'Z6/ <br /> Mailing Address (il di/(erenl): _ __ <br /> i City: ___ _ Stale. _ Zip: __ <br /> ! EmaiC __ ��arret-r�lZ� comutrf n�t Phone: (yZSj 339 -LZ3� <br /> Total Cost to Instali Device (lrom cont�acfor invoice): 5 � la�/ <br /> l-p' _ <br /> Please verlfy the following: <br /> � I am the orJner of the property e�here the backeraler prevenlion device�vas installed. <br /> � I worked wiih the conlractor to determine the localion for the backwater preveMion dewce and <br /> unders�and lhat fhe decision regarding the localion o(Ihe device was mine <br /> � My conlractor mstrucled rne how lo access, inspecl, and mamtain the device. <br /> ;/ I understand ihat I am responsible for mainlaining Ihe backwater prevention device and keeping <br /> r it in goad workinc�order, unless d is mstalled in the city right-o(-way <br /> ��j If I sell my property, I �vill make potential buyers aware of the back�valer prevention device and <br /> the need lo inspect and mainlain if on a regular basis <br /> ��l I �m enclosiny all of the necessary papenvork (use the yello�v Reliale Submiltal Checklis�). <br /> � <br /> Select(rom the following: <br /> i,] The conlrador idenlified downspouts or other drainage Ilines thal�eere connected to my sewer <br /> hne(bet�ti�een my house and the installed device) and removed, or rerouled thern. <br /> 6i, To my knowledgc, my property has no do�vnspouls or other drainagc connecled lo my sewer line <br /> (between my house and the mslalled dewce). <br /> � Thcre aro downspouls or othar drainaga lines connected to my sewer Ilne (DeNreen my house <br /> anA fh� InslAllecl devi^e) 1 u�derstand thei'eavin� ;hese conneclions aaales a risk of flooding • <br /> and I accept�hat nsk. <br /> I � � �,��—_ <br /> � <br /> Signatu�e ,�,�6�,�,,u�,al� Date S 'ZS"- /S� <br />