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i <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Fo�m <br /> Property Owner Name: '"�o n., A N^� 5^' �� <br /> Installalion Address: Zl2t WETr-+oRE R�c <br /> CIIY: E��t%T State: WR� Zip: 98Z�1 <br /> Mailing Address(il di(lerent): ' — <br /> City: State: _Zip: <br /> Email: '�o..,�',1\\au9�,',•,�w oa�-,00. �om Phone: (42S)'u'9-bob0 <br /> Tolal Cosl to Install Device (/rom contractorinvoiceJ: 5 ��,�� Q� <br /> Please verify the following: <br /> �am the owner ot the property where the backwater prevention device was installed. <br /> �worked with the contractor to determine the location for the backwater prevention device and <br /> undersland that the decision regarding the location of the device was mine. <br /> �conlraclor i��structed me how lo access, inspect, and maintain Ihe device. <br /> I understand tt.at 1 am responsible for maintaining the backwater prevention device and keeping <br /> it ip.good working order, unless il is inslalled in the city right-of-�vay. <br /> [r�" If 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 /> - I am enclosing all�o(the necessary papenvork(use the yellow Rebale Submittal Checklist). <br /> Select from the following: <br /> (�e contraclor identified downspouls or other drainage �lines thal were connecled lo my sewer <br /> line (belween my house and the installed device)and removed,or rerouted lhern. <br /> [-] To my knowledoe, my property lias no downspouts or other drainage connected lo my sewer lir.e <br /> (bchvecn my house and lhe inslalled device). <br /> ❑ There are downspouts or other drainage lines connecled to my sewer line(between my house <br /> and the installed device). I undersland lhal leaving these c:onnections creates a risk of Oooding <br /> and I accept that risk. <br /> Si nature v�� v � Date �� ��7 � �� <br /> 9 <br /> / - ��� /O --/'J� �'`� <br /> �� —�-,-+ <br />