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� <br />�� <br />a+' ,� �s �i r� `�s : �' _4 � � i ;. •�: . S � `r <br />� � .l... : �.,�; � . i :', �.f <br />Properky Owner Narr <br />lnstallation Address: <br />n � ���_ �' `�1✓Y� � <br />City_ �_,Ey'�'�" Staie: <br />� <br />Maiiing Address (ifdifierent): <br />City: State: Zip: <br />Emaif: Phone: �f?� �?7c� 's r"x'� � <br />Total Cost ta Install Deuice (from contractorinvoice): $ ���[ °�� <br />Piease veri�y fhe follovving: <br />� 1 am the owner of the properiy where the backwater prevention de�ice was installed. <br />�f w�rked with the cdnfracfor to determine the location for ihe bacicwa#er prevention de�€ce and <br />understand that the decision regarding the iocatian of the device was mine. <br />[�+ My contracior irtstructed me haw to access, inspect, and maintain fhe device. <br />f <br />�I understand that I am responsibfe for maintaining fhe backwater prevention device and keeping <br />it in gaod working arder, unless it is instaHed in the city right-ofi way. <br />[� If f sefl my property, l will make po#ent'sal buyers aware of the backwater preventian device and <br />the need ta inspect and mainfain it on a reguiar basis. <br />•� i am encfosing all af the necessary paperwork (use the yetiaw Rebate Submiiial Checklist). <br />selecf fro¢n the foilow�ng: <br />❑ The contractor identified dawnspouts or other drainage Ilines that were connected #o my sewer <br />line (between my house and the instafled de�ice) and remaved, or rerouted them. <br />[�j To my knawledge, my property has no dov�►nspouts or other drainage connected to my sewer iine <br />{between my house and the installed devicej. <br />❑ There are downspouts or other drainage lines connecfed to my sewer line {between my house <br />and the insfalled device). i understand that leaving these connections creafes a risk o# floading <br />and I accept that risk. <br />� <br />�r <br />- ys. � �� <br />