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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: Camantha I�Pnrinrcnn <br /> Installation Addres�: ?_523 Maf71e St <br /> City: EVefett Stale: WA Zip: 98201 <br /> Mailing Address (il diHerenq: <br /> City: State: _ Zip: <br /> Email: samhen77@gmail.com Phone: ( 42�5 442-4150 <br /> c.a <br /> Tolal Cost to Install Device (lrom contractor invoice): $� <br /> Please verify the tullowing: ' <br /> � I am the owner o1 the property where Ihe backwater prevention device was installed. <br /> �f I worked�vilh the contractor to determine the localion tor the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> � My contraGor instructed me how to access, ins�er.t, and maintain the device. <br /> � I understand that I am responsible for mainlainino !�ie backwater prevention device and keeping <br /> it in good working order, unless it is inslalled in the city right-of•way. <br /> � If I sell my �roperty, I will make polenlial buyers aware of the backwaler prevention device and <br /> lhe need to inspecl and mainlain it on a regular basis. <br /> � I am enclosing all of the necessary papenvork (use the yellow Rebale Submitlal Checklist). <br /> Scicct from the Tollowing: <br /> ❑ The conlraclor iticntificd downspouts or other drai�iage Ilines that were connected to my sewer <br /> line (belween my house and Ihe inslalled device) and removed, or rerouled them. <br /> � To my knowtedge, my property has no downspouls or olher drainage connected to my sewei line <br /> (helween my house and Ihe installed device). <br /> r_] 7here are downspouts or other drainage lines connected to my sewer line (between my house <br /> and Ihe installed drvice). I understand thal leaving these connections creales a risk o((looding <br /> and I accept that risk. <br /> Signature=�U-h���¢ YrP��'�B� Date July 9, 2015 <br />