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/� Back�vater Prevention Device Rebate Program <br /> ��__ Rebate Application Form <br /> w�r` <br /> �.� <br /> Property O�vner Name: Colleen Gamman <br /> Inslaliation Address: 1832 Wetmore Ave <br /> City: Everett State: WA_ Zip:98201 <br /> hlailing Address(il diNerent): <br /> City State: 2ip: <br /> cmaiL• su:acl¢9A20t@amail.comnnc.iortunc@gmail.co Phono: (425) 252-6319 <br /> Total Cosl to Install Device(trom conbacfor �^��oice)' $ <br /> Please verify the tollowing: <br /> [� I am the owner of tho proparty Khere the back�vater prevention device v+es installed. <br /> 0 I worked with the contrector to cletermine the locauon for me backwater prevention device and <br /> undefstand that the decision regarding the bcation of the device wes mine. <br /> � My contractor instrucled me ho�v to actess, inspect, and maintain the device. <br /> � I unde�stand that I am responsibte for mamtaining the backwater prevention device and ka�p�ng <br /> it in good working order, unless il Is instalted in the city right-o(-way. <br /> 0 If I sell my propetly, I will make potenliai buyers aware uf the backwater prevention dctvice and <br /> Ihe neeC to inspect and mamtain it on a icgular basis. <br /> 0 I am enclosing all ot the necessaty papenvork (use tha yeilow Rebate Submittal Checklist). <br /> Setett irom the(ollowing: <br /> �� T e coMrdctor idenUfed downspouts or olher drainage Ilines that were connecled to my sewer <br /> �e(between my house and the installed device) and removed, or rerou�zd Ihem. <br /> To my kno�aledge,my property has no dovmspouts or other Arainage wnneCted to my sewur line <br /> (bohveei� my house and Uie installed device). <br /> ❑ There are downspouts or other drainage li�es connecled to my sewer Iine (belween my house <br /> and the installed device), I undersland that leaviny tnase connectiona creates a risk of Oooding <br /> and I accept that risk <br /> Sigrtetur 3to <br />