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i <br /> i <br /> i <br /> I <br /> Backwater Prevention Device Rebate Program � <br /> Rebate Application Form � <br /> � <br /> i <br /> ; <br /> , <br /> Prcperty Owner Name: Gary G. DeMello-Wells � <br /> � <br /> Inslallntion Address: 1830 Oakes Avenue : <br /> i <br /> Ciry. Everett State: WA ZiP; 98201 ; <br /> i <br /> Mailing Address(i/diflerenf): Sdme <br /> City: Same State: Same Zip:Same � <br /> Email: garygwChotmail.com Phone: (42�_255-4330 � <br /> Total Cost to'nslall Device (fiom contractorinvoiceJ:$ 2�499.59 � <br /> i <br /> Please verify ��ie following: <br /> � I am ihe owner of the property where the backwater prevenlion device was installed. 1 <br /> Q I worked with the contractor to determine ihe location for the backwater prevention device and ' <br /> understand that the de�ision regarding the localion of the device �vas mine. ' <br /> � My contractor instructed me how to access, inspect, and maintain lhe device. <br /> [] I understand thal I am responsible for maintaining the backwater prevention device and keeping ! <br /> it in good working order, untess it is instailed in the ciry right-of-way. <br /> i <br /> Es If I sell my property, I will make polential buyers aware of the backwater prevention device and i <br /> Ihe need to inspecl and maintain il on a regular basis. <br /> 0 I am enclosing atl of tiie necessary papeRvoik (use the yeliow Rebate Submittal Checklist). � <br /> Select from thc following: ! <br /> ❑ The coNracbr idenlified downspouts or other drainage Ilines that were connected to my sewer � <br /> line (between my house �nd Iha inslalled device) and removed, or rerouted them. I <br /> f] To my hnowledge, my property has no downspouls or other drainage connected to my sewer line • <br /> (behveen my house and Ihe inslalled device). ' <br /> ❑ There are downspouts or otlier drainage lines connected to my sewer line (behveen my house ' <br /> and the installed device). I understand ihat leaving these connections creates a risk of ilooding � <br /> and I accept Iha sk� ' <br /> I <br /> � <br /> j <br /> Signature Date 13-March•2015 f <br /> Gary G.DeM1feilo� <br /> i <br /> I <br />