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4 Backwater Prevention Device Rebate Program' <br />Rebate Application Form <br />Property Owner Name: _ Iimy, tY7f%rMA-1,j <br />Installation Address: 1924 Vioz; to r A A Vm-j r';5 <br />City: s✓e -I-T State: WAS l+ Zip: 98ZO <br />Mailing Address (if different): 1052(- $kA +1_1 GI?Y "A" <br />City: M.00 1 ✓34+jo k. State: WAS W. Zip_98L13 <br />Email: -�y4 �• kofF,�,a.[� �otan_v G o m Phone: (�Zy) �'ta' 3Co l¢ <br />I• Total Cost Cost to Install Device (from contractor invoice): 5 2 ( g8 <br />Please verify the following: <br />lam the owner or the property where the backwater prevention device was installed. <br />[f I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />U y contractor instructed me how to access, inspect, and maintain the device. <br />understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />01�11` I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />U r am enclosing all.of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />M"The contractor identified downspouts or other drainage (lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature G ✓tf/ Date �f 9 01 <br />