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� . ... „ r;. . � . • :�i ' . �I ` r. , :. ;� �. �', � '� <br />^ �: �: :�.. . ..... <br />�, .{ c� �., :�. ,i � : F . �:�. :. <br />�"r� \ <br />Property Owner I�ame; ��.��Yl �'' �i �� �Y'�_—___� '�� i�,...�t ._(�%� <br />Instailation Address: � �,r"i � Y�--�-8�( <br />7 <br />City: � t) �E'il.�..Q� State: —�� Zip: - - <br />Mailing Address (if differentj: <br />Ci#y: <br />Err►ail: <br />State: Zip:. <br />Phone: �� ��l'J - r��1�(� <br />7otal Cost to Instatl Device (from confractorinvoice): $ ��,C� 1, O X <br />P6eas� ver6fry the fo93eewirag: <br />� I am the ownsr of the praperty uvhere the backwater pcevention device was insfalled. <br />I worked with fhe contractor ta determine the locatian for the backwater prevention device and <br />understand th�t the decision regarding fhe locafion of the device was mine. <br />� My contraetor instruc#ed me how to aceess, inspect, and mai�tain fhe device. <br />�I understand fhat 1 am responsibfe for maintaining the backwater preveniion device �nd keeping <br />it in good working order, unless it is installed 9n the city right-af-way. <br />�t# I sell my praperty, ! will make potential buyers aware of fhe backwater preventian deuice and <br />the need to inspect and maintain it on a regutar basis. <br />[�,.I am enclosing aN of ihe necessary papetwark (use the yeflow Rebate Submiital Checklist}. <br />� <br />Setect from the #ollqwing: <br />❑ The contractor identifeQ downspouts or other drainage Ifines that were connected to my sewer <br />Iine {between my house and #he installed device) and removed, ar rerouted them. <br />�Ta my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my hause and the instalfed device)_ <br />❑ There are downspaufs or other drainage iines connecied fo my sewer line {between my house <br />and the installed device). I und�rstand that leaving these connections creates a risk of flooding <br />and 1 accept that risk. <br />-.�. <br />Sig�aa�a�re i�T--�� Date �- � ��' <br />