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Backwater Prevention Device Rebate Program <br /> Rebate Applicatio� Form <br /> ProE,ertyOwnerName: ��2R`� Tr�ohA! W�,�}�ZRHUG-G _ <br /> Installation Address: 4"?2`'~ YE�� �2. <br /> City: �✓�2� State: WA 2ip: ���0� <br /> Mailing Address (if diHerent): <br /> City: State: Zip: <br /> Email: J6R�i0GG- ^i G-h41 l., c�.ti+ Phone:(ao�) —1�y S 1�.-3 <br /> 7otal Cost to Install Device(Irom contractor invoice):$��� � � � <br /> Please verify the foilowing: <br /> �I am the owner of the property where the backwater prevention device was installed. <br /> �" I worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding tha locatfon ot the device was mine. <br /> � My conlractor instructed me how lo access, inspect, and maintain lhe device. <br /> �understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> �,,1'If I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. - <br /> �� I am enclosing all of the necessary paperwork(use the yellow Rebate Submil�al Checklist). <br /> Select from the following: <br /> [] The coNractor identified downspouls or other drainage Ilines that were connected to my sewer <br /> line(between my house and the instailed device)and removed, or rerouted them. <br /> �' To my knowledge, my prcperty has no downspouts or olher drainage connected to my sewer line <br /> (belween my house and the inslalied device). <br /> 0 There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the installed device). I undarsland that leaving these connections creates a risk of(looding <br /> and I accepl that risk. � <br /> Signat ate I ��Q D� �y- <br />