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i <br /> � <br /> � <br /> � <br /> � <br /> � �ackuvater PreveroQ9s�n Device �?ebate �'ro�ram ' <br /> �,. Rebafe Application Form � <br /> I <br /> � <br /> - ---- f <br /> Propr.nyOlvncrNome: JI-tii•r� I��.����Rc'�I (��c.lVi I� i I I � <br /> Inslallation Address: L���I IU �I � _ �� <br /> c�q�: L-'UlZ1/C%t�---Os�ai�i: V� f� z�p:__ �l�/,?-Zil i <br /> �Ulailing Address (if difleront): C ' � • � e l� s l s I i <br /> / i <br /> Ciry: L� n.�.vi.� r� -- State: � A" 7rp qS D � � 4 <br /> ��. .�Q @ R?µ��•�+�� 1(��V p (j''(� $.S4 6L$�! � � <br /> Emall: M 4 �Co Pl�one. <br /> � ��.- i <br /> Total Cost to Inshll Device(liom confrar.lor invofce):5 �����1•��� ! <br /> � <br /> � <br /> Ptcase verity the following: j <br /> �'I am lhe n�vner o(tho propery v:hore Iha backwater prevuntion davice was installed. , <br /> pq'I worked vrith Ihe contrector lo d�lermine lhe localion for the baciewater p evontion dovlce and ! <br /> understand that the d�r,�sion regarding lhe location of(he device was mine. � <br /> ; <br /> �tity contractor laslrucled mo haw to access,fn.pr.r,t,and moinlain the device. <br /> �unAersland that I am responsible for mainl�ining lhe back�vater prevention dovice and keeping � <br /> it In geod eror!cing order,unless it is insfalled In the city right-ot-�vay. <br /> I� I(I sell my pmperty, I wili make potontiat buyera aware of tho backv�aler prevenUon device and ; <br /> � Ihe nead to inspect and maintain it on a rcgWor hnsis. <br /> �I eun r.nclosing nll of ih�necossnry paporxork(uce Biu ycllovi Robole Su�mittal Checklist). I <br /> Soioct from thc follo�ving: � <br /> i <br /> ❑ lhA cont�aclor ldanlifiud downspovls nr other dminago Ilines thnt wero conneeted to my s�wer i <br /> line(bohveen my house and the inslaUcd duvico)anA romovod,or rerouted tiiom. � <br /> ; <br /> ,-T,�i To my know.ledge, my picpeily has no dotvnspouts or ather dralnage connected to my sawer Ilnn j <br /> (belween my house and Ihe inslalled device). <br /> i <br /> ❑ lhore are davn,pouls or other drainage lines connecled to my sewor iine(beRveen my house I <br /> ond Iho(nst:,�ied devir.e) I undnrsland Ihal Ie�ving these conneclions crcates a nsk of iloodinc� � <br /> and I accopt that risk. ; <br /> �` <br /> 1 <br /> r �,� ^ i � <br /> Signaturc___J�'�'v� ��' .--Date y � u �'� i <br /> 1 <br /> , <br /> , <br /> , <br /> t <br /> , <br /> ; <br /> � <br />