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�' ,�'� �� <br />� . ... � � . <br />� ,� ,;, , <br />E� " u , ,,. r Reti <br />, ♦ .,�� ' . - .�A , c. <br />Broperly owner Name�: <br />� <br />ate Application <br />! I -. . . . ..� <br />1 �, i <br />� <br />:. , ztia.„, ... <br />Form.`, � �,� •� �„ �: :.� <br />Y C i. Y2-S/�.? W\: '., i�: <br />. .. .� � - . - .. t a',i <br />.. :,i . •v�.t.. ....,�.�-.� ..er�v�e' <br />� � ' . • :.l <br />�r.� �Cl. r _.e..' � <br />lnstallation Address �. 1)-I_ W l'�Y.1�1_Y_ � ��LL. � . <br />City: �� Sta e: �___ ZiF�:�U� J-- <br />Mailiny Address (il difle�en!): _��F . ,_. _ .. <br />Ci�y _ _ Slale' _ Z�P I <br />Emall�. ����j,L�.�i�i.:1�_� ` 4Y.•] � L_ Phone� (YZ� � D��. I <br />Tolal Casl lo Install Devicc (/rom contracro� invoice). S �Y_. #_�1e .p p --= I <br />J <br />.Please verify the:following: <br />�� am Ihe o�+'ne• o( tlie properiy v+hero ihe backwater prevenlion device was mstalled <br />�/(worked wdh Uie conlraclor to determine the�loca'�on for Ihe backwater prevenlion dewce and <br />ndersland thal lhe�decision regarding the loca6on ol.lhe device was mine. <br />�My coiilraUor instructed me how to access, inspect, and mamtain the dewce. <br />�1 undcr.stand Ihal 1 am�responsiblr.loF inaintaining the backwater prevention deUice anA keeping <br />d in good workiny order,�unless il i; inslalled in.lhe city' righl-of-way. <br />[x I( I scll my propeRy, I w�ll make poleMial liiryers aware of lhe backwalcr Urevenlion dewce and <br />Ihe need lo inspect and mainlain.it on a regular basis. � <br />�I am enclqsing :f)I oi Ihe necessary'paperwork-.(use lhc yellow Retiale Subniittal Checklist). <br />Select from the following: <br />�) The�conUactor idenhfiud du�vnspuuls or other drainage Ilines Ihal were conaecteJ to my se.wer <br />lir}g, (hr.lween my house and Ihe inslalled Aevir.e) and remnved, or rerouted Ihem. <br />u�� my knowledgq my Uroperty has no downspouts or other drainayc r.onneGed to my sewer line <br />(betvi�een my house antl Qie installed device). <br />[� 1 herr, are downspouts or other Aramage Imes connecled to my. se�ver Ime (be�veen myhause <br />� and Ihr. mslalled devica�). I underN�nd Ihat Ieaviny �hese c.onneclion§ creates a�risk til.0ooding <br />and I acccul Ihat nsk. <br />/ - i <br />�Signafure _ � . —_�Dafe � 1 �. � � <br />