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�. .M' �._ � �..: � 'y' � � +. d �� • i'. -. p .. <br />��� � � ♦. � ` i�- � � �� . <br />Prope�ty Owner Name: � �.c,,,, �'�� V` <br />InstallationAddress: s�"��'�&' ��°��`�� � -�-� <br />City: "`�`t���°�''-»�� State: �=� <br />Mailing /�ddress (if differentJ_ <br />Clty: <br />Email: <br />State: <br />Zip: �€�~ �� � <br />Phane: ( <br />�� <br />Total Cost to install Device (from contractorinvoice}: $ `-� � <br />PI+2�S8 V@P1�/ ��1� �OIIOWtti�: <br />�am the owner rif the pro�erty where the backw�ter preven#ian �ievice was installed. <br />(�`f worked with the contractc�r to d�termine the locatian for the ba�kwater preventian device and <br />understand tha# the decisii�n regarding the location of the device was mine. <br />�N"iy contractor instructed rne how to access, inspect, and maintain the device. <br />�pGnderstand that I am resp4nsible for maintaining the backwater prevention device and keeping <br />it in ood working order, unless it is installed in the city right-af way. <br />f I sell my property, I will make potential buyers aware af the backwater prevention device artd <br />he need tcr inspect and maint�in it on a regular b�sis. <br />m enclosing alf af the necessary paperwork {use the yeilow Rebate Submittal Checklist). <br />Select frorn the iollawing: <br />❑ 7he cnr�tractor identified downspouts or ather drain�ge Ilines th�t were conneeted to my sewer <br />line (be en my house anti the installed d�evic�) and removed;: or rerouted ihem. <br />o my knowledge, my property has na downsp�u#s ar other drainage conn�cted #a my sewer line <br />(betvueen my house and the ins#alled device�. <br />❑ There are downspouts or other drainag� lines ct�nnected to my s�:wer Iine (beiween my hc�use <br />and the inst�lled device). I understand that teaving thes� connections crea;tes a risic c�f flooding <br />�nd I a�cepi that risk. <br />C?ate �°°°"y��"��� . <br />