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i <br /> � <br /> 1 <br /> i <br /> /� Backwater Prevention Device Rebate Program � <br /> �M��.r Rebate Application Form � <br /> :�3..�,. <br /> I <br /> � <br /> Properiy O�vner Name: Ryan and Jill Dvse�cr � <br /> installation Address: 2019 ColbV Avenue � <br /> � <br /> ! <br /> �iy: Gverctt Slale: 1VA Zip: 9R7�1 � <br /> Mailing Address(itdillarent): � <br /> � <br /> Ciy: State: Z�P� � <br /> Email: lebysegger@gmail.com Phone: (206�704-iR38 � <br /> , <br /> Total Cost to Install Device(from contractor invoice):$ 2•499.59 � <br /> � <br /> � 4 <br /> i <br /> Ple se verlry the Following: � <br /> i <br /> i <br /> I m the owner of the property where the backwaler prevention device was installed. + <br /> I worked with the contractor to determine ihe location (or th.e 6ackwaler prevention device and � <br /> [�nderstand that the decision regarding the location of the cevioe was mine. ' <br /> My contraclor instruded me hovr to access, inspecl, and maintain the device. � <br /> � understand that I am responsibie for maintaining the baeinvater prevention device and keeping � <br /> t in good working order, unless it is installed ii;the ciry right-o(-way. � <br /> [�If I sell my property, I will make potential buyers aware of lhe backwater prevention device and i <br /> lhe need to inspect and maintain it on a regular basis. f <br /> � am enclosing all of the necessary papenraork(use lhe yeilow Rebate Submittal Checklisl). � <br /> Select from the following: � <br /> ❑ The conlractor identified downspouls or other drainage Ilines ihat were connecied to my sewer � <br /> line(belween my house and the installed device)and removed,or rerouled them. <br /> To my knowledc�e, my property has no davnspouts or other drainage connected to my sewer I!ne <br /> (behveen my house and the installed device). � <br /> ❑ There are downspouts or other drainage Iines connecled to my sewer line(between my house � <br /> and the instalied device). I understand that leaving lhese conneclions craates a risk of�ooding � <br /> and I accept thal�isk. , <br /> 'r <br /> � <br /> / f i <br /> Signature ! ' _ Date � �� ; <br /> \ � <br /> � <br />