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Backwater Prevention Device Rebate Program <br />Rebate ARplication Form <br />PropertyOwnerName: iMr</�.4�'� /� �"����� <br />Installation Address: ��{ 2.0 0/ ��4/t' "1 <br />City: E V6/t61T Stale: wA Zip: 9�Zo I <br />Mailing Address (iI dilferei�t): <br />Cliy: <br />Email: <br />State: <br />Phone: ( <br />TotaFCost to Install Device (from contractorinvoice): $��J�- �o _ <br />Please verify the following: <br />[� I am ihe owner of lhe property where the �ackwater prevenlion device was installed. <br />I�l I worked with the conlractor to delermine the location for the backwater prevention device and <br />7� undersland thal the decision regarding the location of the device was mine. <br />[� My contraclor inslructed me how to access, inspect, and mainlain Ihe device. <br />�} I understand lhat I am responsible for maintaining the backwater prevention davice and keeping <br />il in good working order, unless it is installed in the city right-of-way. <br />� ILI sell my property, I will make potential buyers aware of the backwater prevEntion device and <br />lhe need to inspecl and maintain it on a regular basis. <br />� I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal C. ��.;klislj. <br />Select from the following: <br />� The conlreclor ;dentified downspouts or other drainage Ilines thal were connected to my sewer <br />line (belween my house and the inslalled device) and removed, or rerouted them. <br />j�) To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(Fatween my house'and Ihe inslalled device). <br />❑ There are downspouts or other drainage hnes connecled to my sewer line (belween my house <br />and the installed device). I understand that leaving lhese connections creates a risk of Flooding <br />and I accepl that risk. . <br />Signature��%%� ���CA� Date /�"/�'/y <br />