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��i��Backwatcr Prevcntion Dcvicc flel�:�tc Progr��rn <br />T Rch:itc Ap��lication Fonn <br />Property Ovnier tvame,�/ifi;))r`5 �' / /2�«'�%-G <br />Inslailaf:on Address: �fI�J %�C � iC Lc-C � <br />� Ciry �J��1_�j- <br />�4oilino Address (il dr(Icrcirf) <br />Cily' — .----- <br />Finail: <br />:�I.dn (I,�L � Zi�i <br />:Stulc _ 7�p <br />I'hunc 1 <br />� <br />1b181 Co51 �o Inslall Devi: c(lr�un r.nnh.irinr u�vr,ir.eJ 5 J�[J � <br />f <br />Plcasc vcrify the following: <br />i <br />[_i I am the owner of ihe property v:herr. Ilie Uir.4,w:ilri �::��venlion cic:ic� ��:,r; in�.,;,in..�l <br />i�' I tvorked ���ilh the contractor lu dr.ir.�niim� �hr. lur.ahon lor tne Ir,ickv::iic� �n,�����;ib�r� il� v�;:r :u .l <br />understand that the decisinn mg.vding Ilie loc�tion of the dewr.o wnr, nunr <br />'"1 hiy contractor instructed n�c hrnv I:� 71Cf.C55, II15�)CCI, �nt) 111;IIIII:IIIi lhc dcv��.�• <br />r� I undCistand Ihai I am respoiis�l�lc Itn in,iin(,iin�ng �I�e b;ickw,tirr piuv��ulwn �b,,:n �, .nvl k� ;yn�ig <br />it in good �vorkiny arder, unles5 il is insl;illad in Ihe �aty nyhl c�f-�v:iy <br />�•]� I( I sell rry property, I will make po�enli�N buyus :twer� of Ihe b;tcP.w:u� •; ��m.vrnhnn il� �v�rc ;md <br />Uie ncec! to inspecl �nd mainlmn il on :i regulir h;isis <br />�.j- I�un enrlosin� .dl of lhe na;:s';:iry �riprnv�xn (u;;o �hC y�tll�nv Rrl�.,i'�� S,.hnult.d (:hccnlr,t) <br />Selcct from thc followin�: <br />�� ��IC (:UIl�filf.�0( I:�Cf1�I�IB(1 t�f1VJl1'qR:lil'. �P u�l'd� 1141111,IfjC ��IfIPc: II1.1; A:t'.�� ��.,"I',i�i li�.; ;�; iii�...���vi`- <br />!me (I:etn�ern my house nnJ ihc ne;l;dir�l �lrv�cr);uid rmnovru. or iriuii'�•�, Ihcn; <br />�� �' Ic my hnowludge, iuy property linti nu down>,��uuls rn nlhcr �h,i�i�.n��� � nnn�•r6�J In inv �,���vri Inu� <br />(bclv,cen my house and Ihe nisl;ilh��l dew�.��) <br />j Ihcrc lu(!(�O�Yi75�i0id5 Ui ulhi•i �li,un.u�r linr��, rui;iic[l��d �ii �ny ..��t•.�-�� hrn (I��.Iv.,����� iiiy ���ur,;• <br />.ind Ihr. inS�dllCd d?viixr) I un�hv�,! inil Ih.d Ic:�wnq �husr t n�un��ii,�ii -� n� i��.���..i u�.F. ��I hrn��hnn <br />:wil I .in ep! Ihal rir,k � . <br />Styrt�ilu�� <br />� <br />; ��jZ3I2vIS <br />— � U.,r�� <br />