Laserfiche WebLink
� Backwate� Prevention Device Rebate Program <br />Rebate Application FQrm <br />�- <br />ProportyOwnerName: �c'�-� ��Ouhc� <br />Installatlon Addmss� '-� �Z 1" �v��"�t-�Y'e �'c <br />City: Cv��-f�I _State: WrT 2ip: �'7� <br />�4a111ngAddressQld7/ierontJ�__�.��� �p�C�,�e,jl �/�:� nJE <br />City: S�' 4'}i-�•� Stale: WA__ 'Lip: 9�I �J <br />Email: 'ti� �raSe�,ki-{e cn�h _Phone:(--�1�` �� �-`f53— <br />Total Cost to Instell Oevica (Irom corVracloNnve(co): 5 ? 9 9 � s�� <br />Please verlfy the tollowing: <br />� I am Iho ownor of the property where Ihe backwaler prevention devlco was installed. <br />�'] 1 worked with Ihe wniractor to determine the localio;. for Uio backwater prevention devicn end <br />y untleretand that the decision ragardiny Ihe IocaUon o( the device was mine. <br />�� My coNraclor Instrucled me how lo access, h�spoct, and maintaln the device. <br />� I undersWnd that I am responsible for maintaining fhe backwater prevention device and keepin0 <br />Il in c�ood working order, unless Il Is Inslalled in the clty rlghFof-way. <br />�] If I sell my property, 1 will make polanlial buyers awaro of �he backW�ler preveMlon device and <br />� lhe need to Inspecl and maintain It on a reguler bas(s. <br />j{�] I am oncloFlne� ail o'� the necessary papenvork (use ihe yellow Rebale Su6tnq�al Checkllst). <br />Select from the foliowing: <br />l� 1 he conVactor ldentlfied downspouts or other dralnage Ilines thot �vero connecled to my sewer <br />lino (belween my house �nd the Installed devic�) and romovod, or reroided Ihem. <br />[� To my knowlodge, my proporty has no downspouls or oRier drainage connucled lo my sewei Ilna <br />(butween my hcuse and Iha Installed dovlco). <br />❑ Thero oro dok�nspouls or other drainege Ilnoe connedod to my sewer line (bsiween my house <br />and Iha Installod davice). I understand that leaving thaso connoctions creales a risk ot Ilooding <br />�nd I accept Ihat risk, <br />�/ / / <br />y Si�nature �/�� Dato '� I Z�r �� <br />