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� Backwatcr Prevention Devicc Rcl�atc Proyr,un <br /> �, r� Rcbatr Application Fonn <br /> Pro�r.rty Owner Narne: _ ��I(�7'� FEJ(�-L�G <br /> I � r <br /> I Insfallahcn Address: _I� �� �l�G��� t4-i�G <br /> ICily. _ _ ;�t.dc 7i�i. <br /> Ma�ling Address (if di(lerenl). <br /> Ci�y: _ ;;I�dr. Zi��� <br /> ErnaiP. _.__ Phonc ( ) <br /> I <br /> I Total Cost�o Inslall Device (Gum cnnbnr.frn invurr.eJ 5 �5 Q�i � <br /> � -- ---- <br /> Pleasc verify the followiny: <br /> [�I am Ihe O�vner 01 lhe properly whcrr. Ihn ���r,kw;3lef pr�venliun �h:v�r.c�v,c� inr:Ldl��d <br /> �j I worked v:dh the conlrar.lor ta dr.tr.nnine the locahon fui llie backw+ihv prr.venbnn dcv�r.c ,urf <br /> unAersland Uial lhe deci;ion rei�orduig !he Incahon of Ihe devicr. wos nunn <br /> ["I h1y contractor inslruCted nlc how In acr.ess,msper.l, and m:�inLiin Ihr. d�•vr.:c <br /> �-' I undcrstand ih�t I am r�.spom;ihlc lui m.unl;uning !he backw;dci prcv��n!inn��cvirc.uul krv�i:�ny <br /> it in yood working o�cler, u^less it is inslallr.d in Ilie�:ity right-of-weiy <br /> � �j II I seil my property. I ti��ill m.�kc putenti.d Iwycrs awar��of Ihr. bncko;�lci pm.vr.n�ion di:wr.c ,�nd <br /> the ne.Mi�o insper,i and m,7mlrlin�I on n ruyular boSis. <br /> �_��I am CnClosil�q all Of Ihe n��Cc,:s:iry p:iparv.•ork (usr Ihc yr.11o�v kubrdr. Subnn�lnl Chrr.hlc�,l) <br /> Sclecl(rom lhc following: <br /> �_� l lic cunlr,�ctor idenlili��d duwns��uul:ui ulhci dnnn;iqct Ihncti Ihnl wrrr �unnri.lr�l In uiy •.��wr� <br /> line(bclween my houtie and Ihe in::talled devir.e)anil icmoveel. u� rcruidc�l U�i•��� <br /> ��j� 7o my knowledge. my property li,r.; nu dnwnsprnds ai olhei iL:nn:iyr c�nuiri.lyd In ury �.r�:rr hui� <br /> (I�clwcen my housc and Ihr. :nsi,dlyd drvicr) . . <br /> � � Ihric�uCdOt:�rlSpOltltiO101hi�iih�unni�rin..�,..�rnni.cicdlnniy �.rw�vLn�� �l��9v.r�•nn�yl��.�u� r <br /> ,inJ Ihc in3l�tllud doviat) I un�f�r.fe.�d Ih.i' li�.rdinq Utr.sc t�unnr�:linm. � i� ,d��•. -i ir.k �il Ilu�ul�n�� <br /> :ind I ncccpl Iha� �i;k. � . <br /> ., ) C' <br /> ti�qn.�(inc_ . _E(/���-- Ualc 7' '�'3_ C� <br />