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�I <br />���;� � • �, r : . .. :�, ., � r. a= <br />� �� .; <br />� ��� i � -' . <br />1 fY, j . F�, �. 4.� , �. j; •.- f E <br />..8e`�/` <br />Praperty Owner Name: <br />install�tion Address: <br />City: <br />�� <br />State: �.,s�'.� Zip: <br />Mailing Address (ifdifferenf): �'"��� ����+�'� �'``�' "`� <br />Ci4y: �`�,,,�u� Siate: }`,�,�d �- Zip: <br />Ernail: <br />Phone: ( <br />Tota[ Cast io lnstall Device (fram contractor invoice): $� � <br />Pl�ase ver6fy tlte foll�wir�g: <br />}! <br />�� <br />� 1 am tf�e owner ofthe property where th� baeEcwater preventian devic� was instatled. <br />�` ! work�d with fhe contr�ctor to de#ermine fhe locatian for the t�ackwater pre�eniion device and <br />understand that the decision regardi�g the ioca#ian of the device was mine. <br />[� My contractor instructed me how to access, inspecY, and maintain the dev'tee. <br />� I understand fhat i am �esponsibEe for maintaining the �iacicwater prevEntion device and keeping <br />it m good working order, unless it is ir�stalled in the city right-of-way. <br />�{fi l seil my property, I wili make potenfiai buyers aware of the backwater prevention device and <br />the need ta inspect and maintain it on a regu}ar basis. <br />� t am enctasing ali of the neces5ary paperwork {use the yellow Rebate Su3amittat Checkiist). <br />Se9�c� ffram the ��6lovvire�: <br />❑ The contractor ident�fied downspouts ar other drainage Ilines #hat were cannected #o my sevver <br />line (between my house and the ins€alled device) and removed, or rerauted them. <br />� To my knowledge, �nY property has nn d�wnspouis or other drsinage connected to my ssu+rer Sine <br />(be�nreen my hause and the instal#ed devicej. <br />❑ There �re ctownspouts or aiher drainage lines cannected to rrty se�nrer Eine (C�eiween rny house <br />and the instalted device). I und�rstand that leaving ihese ct�nnectians creates a risk af ilooding <br />and 1 accept tl�at risk. <br />��� `� ���t'�� � � <br />Signa#ure �a Date� � f �- � �� <br />