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<br /> Property Owner N[T�e � om' � �� + ��f � �m ��ry`3`� k�. • �' rr e' ',
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<br /> � ' InstallaUon�dd��ss 1620 WeEmore r ti x"� + r"•' kti �+i. �
<br /> � ��%.'r � /•' � ��•Y G :��.. , N-C' `� r _.;�,a ��F�`.y y� M N.� i
<br /> City. Eveiett State: WA `' �' Zip;98201 •• �.�a. '� � - �
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<br /> ^^..�i���g Address(AdiHerent): ���i'�
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<br /> ��Ci �` - Slate Zi ' � ` ' '
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<br /> Emaii: mikn�nct�llousa(a�mail com• PhOne (425); � � + �k��
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<br /> Tolal Cost to In�tall Device(Irom contraclor invofce) $ 2 402 40 _ ��_.; � �Kh v 1 � i
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<br /> ` Please verify,the fo�owm9 ' ' , �1 , ; �" ,ef�,aY�! ^•. '
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<br /> , � 5�14� {; ..s'��,�"�� "'r��; '� �' ' r - t Y '^ ~ ��r��'�. r 47�'> � . .�xt ` ��
<br /> Q I am the oWner of the prop�Ay wh�ere the bacfcwater prevention de3ice, as mstalle�i;� '� � •Q�� � �� I
<br /> � �1 � � ��,t • � r � � - P�i a:r`y �� .. �'.lr � ! W �e� S�n r r� �T•.��•'I
<br /> � ,�'�i �l w�rke�v�ilh�the contrac�or;to�1�ermine th e�_Ocafion ior.the backw'ate��entioh�dewCe nd � �.,:` �
<br /> unders�tan,d� tlia i� decisah e9a d n Tthe'l o�atwn�f t he d�I'ce'Wec�F i i���r t 5'4,; �"� , : ;
<br /> � i � ���.c�1�`*' ��',�tiS2�4'F �s ��y,�' �.��f �^� r..r ^i�' .f.�.t�V{+1.'�� C� ��.�i�;�, i �7�```tbi. .I
<br /> •�;Or My edt�iX�cvor ina�ded�e howit�,a�rcce�se�spect�Y�d mai�tain�e de��i(�� ,Y!y�£ f � ;�yl ,
<br /> :� � 9 understand thatil am�e�ponSible(o�maintaimng'the backweter p�evenHon deviceDand kee�g � � : :. i
<br /> d in'gdctd Wo�king ord'er' un'less d i�mstalled in the cdy rlghl-oi way . '�: � r '�. ` <�,. ,� �
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<br /> �•Jf 1 sell my prope'rty I w�l�make¢ot8ntl�l�uyers aware o(the backwater p�eventlon�device 8nd.y=
<br /> I Yhe need to`inspect and�aintamnt o�a regular basi� ; , '; ��; A�;�.;� f
<br /> i � I am'enclosmg ail of 1he necessary paperwork(use the yellow Rebate�Submittal Checkllst) "�^F I
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<br /> Selpct1from the following s • , ' �
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<br /> I ❑ The conlracto�_�dentified downspouts or other drainage Ilm�s that were conne��edtito my sew�j �
<br /> , Iine.(between my house and ihe installed aewc�)�antl removed oY�erout8d them ., �,n_,y�<< < , , �
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<br /> � � ❑ To my knowledg� my property has no d�Wnspouts or other dramage connetted to�my,µsewe ine��, - . �
<br /> (between my house and fhe mstalletl device) ;' ` ''� ' ,� i ^�7,(�.�:�' ; t ' '�
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<br /> '` Q 'There are down p uls orotheJ dr�inage Imes connecled to qiy sewep�,linye(b�hvge�,rpy hom,$,g� i��, ,: ' �
<br /> and.the inslallc�tl dewee)SI underaland )hat loavmg these connec'hons creales e n`sk o�floodir�gy s ; i
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