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.. . �� : �. ��. �� �. �� � 'i; <�: �` .� �: <br />� :. <br />;� ,� ._ . 1 � .� : - � . , .� , .., <br />Proper'ly Owner �larr <br />installation Address: <br />Ci#y: ��� Staie: �ip: � ��� t <br />Ma�iing Address (if difi`erent): <br />Ci4y: <br />�mail: <br />State: ziP� <br />Phane: ��,J`�L - <br />i'ota! Cost to knstail Device (from contractorinvoice): $ o�c ��.�, >�� <br />Please veri#y the fo96o�n►ir�g: <br />[�l am the owner of the praperty where the backwater prevention de�ice was installed. <br />� worketi wiih ihe contracior fo determine the laca#ian for the bacicwater prevention device and <br />undersfand that the decision regarding the location of the device was mine. <br />dMy contracior instructed me hnw to access> inspect, and maintain the device. <br />�/I undersiand that 1 am responsibte for maintaining #he bac{cwater prevention device and keeping <br />it �n good working arcier, unless it is installed in the city right of-way. <br />[�Vf I sefl rr�y property, l wilE make potentiaf buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. _, <br />�! am enclosing all of the necessary papen�vork (use the yeilow Rebate Submittal Checklist)• <br />Selec� frcean the f�llovuing: <br />❑ ihe contractor identified downspouts ar other drainage Ifines that were connected to my sewer <br />lin� (bei�ween my hause and fhe insfalfed device) and rernoved, ar rerouted #hem. <br />�o my knowfedge, mY Froperly has no downspouts or ather drainage cannected to my sewer I'sne <br />(between my house and the insta€led dev�ce). <br />❑ There are dnwnspouis or ather drainage lines co�necied io my sewer iine (between my house <br />and the instaHed de�ice}. I understand that leaving these canneciians creates a risk af fiooding <br />and 1 accept that risk. <br />Sc��ai�r� �.-� w--Q- `�nS� oaie y � <br />