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i <br /> 1 <br /> ! <br /> i <br /> - . � <br /> � 9!`�6��.i d.....�.�e s- : i a.. vv..... -v� .�.... ea•.�.� . .. . n_.. � <br /> '�� h�na�i� e���Ndi�;a�ie��ir�c��� ' <br /> � <br /> ------- --I--- -- i <br /> -' r �i�, l 'IW`.-� � �/ � � <br /> ` ,-7.�f7:! UVJf1Bf N8��0: _�. �� �—.- I <br /> I <br /> i InstafiauonAddres:: I5 �( �orr��rz1_ /_`��—_ _ i <br /> �• � <br /> ' ^,m�: �..1 u-2�� S:a[e:���.– —�Zio: �Yi 2�-�— - --- ' <br /> � ivlaili�� �;e essfildiftero��q _� � �!'i,�. r✓''_� F ' ! <br /> � Cuv ,__�'^l�..r��i � � State: � _ "uu:�D z-�. � � i <br /> `-' ----r - - - �- - � <br /> ; cmaii: '1"V���.w.� .....—� ( � �J^-�- rnone: iy� Z31 • y� ��_ � <br /> I lblal Cosl to Install Device(/rom coniractor inw�ic�i: a 7 � �1� S�o i 1 <br /> -- ----- � <br /> • - 1 <br /> ,J�am the owner of the propertv where the backwater nreveniion device was instailec ! <br /> '':C� iri(h u�c Cui�ifHCi'vT iGlic�c(Riii�c��1c iOC'o'iG�i0i iiic u6Cnti"+alci ufcVcilii�ii Cicb�iCc oil(�i � <br /> ., j <br /> understand that the decision regarding lhe location o(the device was mine. i <br /> _ . ............... ....,,,,,....,.. .,,.. ..,... ..,..,...�..,.,. ., .. �, , 1 <br /> U 1 understand that I am responsible for maintaining the backwater prevention device and keeping � <br /> �- �- ---- '::;;;iJri;] ,-,rG�r. � - --.... .- �- f��AiaFa�i Irt in:;::ItV r - - -. <br /> .� .. ... iunno u i.� u� . � <br /> � � 1 <br /> ❑ If I sell my property, I will make potential buyers aware of Ihe backwaler prevenlion device and i <br /> illc i�v-cG i'v iiia�cCi ai�O i�iBiiiiiiii� ii 'vii o i .-�iiirif i�riSiS. <br /> �_� I am enclosing all o(lhe necessary paperwork(use the yellow Rebate Submittal Checklisi). I <br /> � <br /> ._ ..... . -......_.... � <br /> .,...�... ....... ..... ............�. <br /> ❑ The contractor identified downspouts or other drainage Ilines that were connecled to my sewer I <br /> 71f1'c IDC[WBCfI fT1V hOl1S0 afltl If1C If15[21iBq OcVIG81 Bil� iEii1J4CG. Of lEfOUiGG [IiB�Y� ! <br /> �To my knowledge, my property has no downspouls or othnr drainage connected to my sewer line � <br /> roeiween my nouse and me instaiied devicej. <br /> =:''�,i here are downspou�s or olher drainage lines connecled to my sewer line (behveen my house ' <br /> ". a�'�i iii2 ifl$�aii2u L�2VICC�. � •�__••�•,•••� ~_��•._••:__ _ • �, a n... ', <br /> �iii�uc�a�ai�v �uo�icavin�i`ic�c CJiliicCiiOiiS Cicoic5 a ii5n O� uw�7lib � <br /> and I accept that risk. ' <br /> /' � � � <br /> ture " �/ � � Date `� — /� ' ��� I <br /> Signa i <br /> � <br /> I <br /> i <br /> f <br /> � <br /> � <br />