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Jul. l6. 2015 ]:35Ah1 Snohomish I�o. 5698 P. I <br /> , �- ��ZS' Z5"2 - .s�7y , <br /> . i <br /> , <br /> Bacicwater Prevention Devlce Rebate Program I <br /> Rebate Application Form j <br /> � <br /> Pro e Ownor Nemo� �/'1 I <br /> p rtY i ^'l e � <br /> InslallallonAddress: � �� �_ I <br /> i,�/ � <br /> CIly:�,'f/Cl�c 61ete: P/�� ZIp:,��74. ,L________ ! <br /> Malling Addross(11 dllloronf): Z y 2 Z��/�c�� � <br /> Clly: / Slale: !�' Z ��i Z 2� ' <br /> �J- y,w�,�'� / ; <br /> Emell: �/P;n / q �Pi�Z-.3� Pha e Q�0) '�35����6 � <br /> Total Cost tolnslall Devlce{from confracfor Invoice): $ 2�� � ,pi� ! <br /> I <br /> i <br /> ; <br /> Plaoew verlfy tl�e lollowin�: <br /> �I am the owner of the property where the baekwaler prt�venllon devlce wae fnslalled. ; <br /> � <br /> ❑ I wo�keJ wllh tho canlr�dor lo delermine lhe IopOon(or Ihe backwaler prevenllon dnvlw and <br /> undersland thal Ihe deelslon regarding lhe loealion oi the devlce was mine. ; <br /> � <br /> [f My �nhoclar Instructed mo how lo accees,InspeG, and malntaln the devlce. <br /> � I undorsfand that I em responelble lor melnlaln(ng Ihe baekwaler p��voo'' :t �uvlce and keeping � <br /> �t In good working onler, unlese II Is Inel�llod In lho clry rlpht•o(-wey. <br /> ❑ If I sell my properly, I wfll make po(entlal bUyAra aware of Ihe bflCkWfller pfevenqDn devlce and i <br /> Ihe need lo Inspeo[and mainla�n il on a regular besis. � <br /> ❑ I um enclo§Ing ull ol tho necessary popenvork (use Ihe yelloW Rebale 9ubmlkel Checkllst). <br /> � <br /> Selcotfrom tha lollowing: ; <br /> � <br /> ❑ Th�conheclor ldunllfied downspouls or other dralnage Ilinee Ihat were conneotod lo my cewor ; <br /> Itne(befwoan my house nntl tne Instollod dovlco)and remoeed,or�erouled 1hom. j <br /> � To my knowlodge, my properly has no downepoula or other dreinego connoGed to tny aewer Une � <br /> (betwee� my houRe and the InstallAd devlce). � <br /> ❑ 7hore ero downepouls or Ather tlralnege Ilnes connected to my sewer Ilne(bdlween my house <br /> end tho Instellod dovlce). I underatond that leavfng theae wnriecGons credteg e dsk of flooding � <br /> and I uxept lhat i1ek. i <br /> � <br /> I. <br /> S/gnsrure�.r�1- � %`-C�wih, —°Date / �%S`� i <br /> � <br /> i <br />