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�� � <br />�; . <br />�� <br />� �' ;' i ' � ' .! . �` �. • .' <br />i. . <br />� �. 1 .. � :�� i ' � :' '��_ ' �. �� -: < : <br />Propetty Owner Narr <br />{nstallation Address: <br />� , /' � <br />, + � _� =w, , � • � + _ <br />��--- - <br />Mai{ing Address (if differenf): <br />City: <br />Email; <br />State: Zip: <br />Phone: � � �.ci ^' �,�LL.> <br />Total Cost Yo install Device (from contractorinvoice): $ c�`C �i.�� � <br />P6ease verify the fa9l�wis�g: <br />�{ am the own�r ofi the property where #he bacfcwater prevention de�ice was instailed. <br />j�'' 1 warked with the contracior fo determine the {ocatian for the backwater prevention de�ice and <br />� understand that the decision �egerding the location of the device was mine. <br />❑ My contractor instrucfed me how io access, inspect, and rrtaintain the device. <br />�! understand that I arr� responsibie for ma'tntaining the backwater prevention device and fceeping <br />it in good working order, unless it is instailed in the ci#y right-af-way. <br />�lf I se{I my property, ! will make poten#ial buyers aware of the backwater prevention de�ice and <br />the need to inspect and maintain it on a regular basis. <br />I am eneiosing aB of the necessary paperwork (use the yeilaw Rebate Submitta! Checkiisfi}. <br />� <br />Se9ect frocn t�e folfowir�g: <br />[] The cort#ractor identified downspovts or other drainage flines that were connected fo my sewer <br />line (beiween my house and the instafled device) and �ernoved, or rerouted them. <br />�To my knowlecige, tnY Property has no downspouts or other drainage connecteci to my sewec iine <br />(beiween my house and the installed device). <br />❑ There are downspouts or other drainage lines ccannected to my sewer #ine (beiwesn my houss <br />and #he instalfed device). 1 understand tha� leavirtg these conneckions creates a risk of floociing <br />and [ accepf that risK. <br />� �_._�.�.,_�__..... ����.��� <br />�;��a���e c���� .� <br />.r �,,,,,�......;`.. <br />