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Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Property Owner Name: _�/�lV { N A���UV'Ci=[�-- <br /> Installation Address: � u��a I<(7CKC te ��2r" ��� f(1,�-�-T� <br /> City: �`Veretl State wA Zip: ��zU�� <br /> Mailing Ac�dress (rl diNerent): � ��� �I.��2+" .�"Tve. <br /> c��y: L�ere �} state: I,�JA z;p: Q.ZD 3 <br /> Email:�e � � �-I �J� �V AhDO. (�.DYvI Pho��: �L5 7(d� -ozs� C�i�J <br /> q2s -31?- 89o} chome) <br /> Total Cost to Install Device (from co�!�actorinvoiceJ: S <br /> Please verify the following: <br /> (�am liie owner of Ihe property whero ihe ba�kwater prevention device�vas instalied. <br /> [�i ��orked with the coniractor to delermine the location for the backwater prevention device and <br /> understand ihat lhe decision regarding the location oi'he device was mine. <br /> �'Niy contractor instructed me how to access, inspect, and maintain the device. <br /> [��I understand tliat I am responsible for maintaining the backwaier prevention device and keeping <br /> i; in good working order, uniess it is installed in the city right-of-way. <br /> �t I sell my property, I will make potential buyers aware oi ihe back�valer prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> ❑ I am enciosing all of lhe necessary paperwork (use the yello�v Rebate Submittal Checklist). <br /> Select irom the following: <br /> ❑ The contractor identified downspouts or other drainage Ilines ihat were connected lo my sewer <br /> line (behveen my house and ihe installed devlce) and removed, or rcrouted them. <br /> �'To my knowledge, rny property has no do�vnspouts or other drainage connecled to my sewer line <br /> (belween my house and the installed device). <br /> �J There are downspouts or othcr drainage lines connecled to my sewer line (between my house <br /> and ihe instailed device). I understand that leaving ihese connections creates a risk o(Oooding <br /> and I accept that risk. <br /> Signafure Date <br />