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Backwatc,r Prevcntioi� Ucvice Rcbatc Prc�c�rriin <br /> \ �,. �,, Rcl���tc Ap��licc�tion Forni <br /> IProperty O�vner N�me �E���l %���� <br /> Inslallaliun Addiess !�L'�-0 (`�/�t�{,J <br /> i <br /> ICily: �i�Ye`L�E i__ :��:i�r l.`-fY /q, I <br /> I�tailing Address (il diflcrcntJ <br /> City. _ f;lnln l.ip. <br /> i F.m�il: _ ---_ . _- . Phunc (�77� �5 7' �/Y z I I <br /> � lblal COSI t0 In5(ell OLvicC (lrom�:nnVtic7nr invuia�). 5 �-'j£�E' � I � <br /> I -- I : <br /> I. _ ; <br /> Pleasc verify the following: ` <br /> �� I am Ihe o�•;ncr o(Ihc propcity whcrc ihc I�,ir.k�.��al��� p;cvcnhun dcwcc v:�is in�;i,dlrii � <br /> I <br /> � I v:or'r;eti with �hA conlractor lo defernunr. ihe loc�fiun lor the backw�iler prr.v��nt�un dcv��:�� ;uid <br /> undcrsland lha! Ihe ciecision rec�a«fing Ihe Inc;dinn of Ihe devi;:r. �v,r; nw�c I <br /> �� My contraclor instrucled me how lo ;ir.r,ess, inspetr,l. and m;iinLiin thr, dr.vinr � <br /> i <br /> (��� I undcrsland fhat I am responsiblr. fui iwunl;ununl Ihc b+ickw,ilci pruvenhnn �Lw,rr .nul k�����nny 1 <br /> il in good�:�urkin� order, iude;s il is inslalled in Il�c city right-of-w;+y. i <br /> (�i llf I sell my property. I will make uutr.nh,d Luycis:iw;uc ol IPc Ir,�r.k�vrdc� p�evr.nuun d�rvu:i�nnd i <br /> Ihe need lu inspect and moinlaui if on :i ro�piLi; b;i;i;. i <br /> i <br /> [.•j'I am enr.lo:ing all of Ihe necess:�ry p,ipertvoiF, (use tl,c ycllu�v f�cli,tlr SiiLrnd;�i! Chnr.klc;t) � <br /> Select trom lhc followin_y: <br /> �_ � I-hC Conlr;iclor id�nlified du'.vm:�iuUL'� ni nllici �I:;un:iq�� Ilutes Ili,�l v:��ic runiu�� I���I hr niy �.i•�,vc� <br /> hnr. (belween my house ��nd �h�� utsl��Vcd devtr.e};ind removrd, o: icruulc�l Ihcni <br /> ���1� io my knav:ledge, itry pfoperly h�L, nu 1 �wn�:p�wis ui o�her d�nm:ig�•t�unnrrir�l !„ iny ,�•..rr Pnr � <br /> (brtwecn my hnuse and ihe insl:illed dr���::i�) <br /> � � Iln�ic :ne dnwnspnuls o�olh�ai drnin:n�c h�u^;r�mnc�:icd lu niy scwi�i hn��(Irr0.vr�vi my lin�i,r 1 <br /> ;ind Ilic u;•,Udled device) I untli�rsC�n�l Ihnl la:ivn;g Ihr.s:��coiumr.hnm, i.ii:,d�^. .i n�.A �d Ilu�nlu�y I <br /> :in�l I :�r�;rpl Ilinl ri:;k . <br /> //�� I <br /> � �� �,,,,�/ �7 I <br /> Slryn;rhur . �/l -- �" '^�`�V Da(c ��� � ��� � <br /> — \��� <br /> I <br /> � <br /> � <br /> I <br /> a <br /> f, <br />