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'-, r �: r �:" 1 � � �- �,.. . i:■ i ;,. <br />' • . � :k .� �' : ' �, , ; <br />Proper#y �wner Name: �„'�(��.�i n � � � �'�'iL� .�i�.-1 <br />Insiaffation Address: _��,� �C'-�t .�!�?� <br />City: ��� State: � Zip: ����, <br />Mailing Address (rf di{ferent): <br />City: <br />EmaiL• <br />Siate: <br />Phone: � i� � '` c� � C� / <br />7�ial Cost to Install Device (from contractorinvoice): $ ��,,,�1 � � ` �s � <br />Pleas� verify 4F�� follovuang: <br />[� 1 am the owner of the property where the backwater prevention device was instailed. <br />[� I worked with ihe cantractor to determine the iocation far the backwater pre�ention device and <br />understand fhat the decisian regarding the �ocation af the de�ice was mine. <br />[�My contracFor instructed me howio access, inspect, and maintain fhe device. <br />[�I understand that 1 am responsibie for maintaining the backwater prevention device and Keeping <br />it in good w�rking order, unless it is installed in the city right-a#-way. <br />[� If I seli my property, l will maice potentia! buyers aware of #he �ackwater preventian device and <br />�fhe neecf to inspect and maintain it on a regular basis. <br />1 am enclosing ail of the necessary paperwark (use the yellow Rebafie Submittal Checkiist). <br />Selec� fram the f�Ifpwirt�: <br />❑ The contractor identified downspouts or other drainage llines that were connected to my sewer <br />[,�ine (between my house and the installed device) and removed, or rerouted them. <br />To my 6cn4wledge, rny pro�erty has no dawnspouts or other drainage connected to my sewer line <br />(between my hause and the instailed device). <br />❑ There are downspouis or other drainage lines connected io my sewer 3ine (�oeiween rr�y house <br />and the instaEled device). I understanci ihat keaving these connections creafes a risk of flooding <br />and 1 accept that risk. <br />Srgcrafer�� Dafe ��� �� � <br />