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� r��. <br />� .: <br />� . � • • . � " +� � r <br />.:; � • <br />�r"' � �-..�_ ` ' i� � �_ . • +� r <br />Pr4perty Qwner Nam <br />instailation Address: <br />Gity_ � State: Zip: �f �.,~�~�� <br />Mailing Address {if differenf): <br />City: <br />Email: <br />5tate: <br />f'hone: ��j`���� � "i �- �"` <br />_ _ _ '-�' ��..�... <br />Total Cost to install Devi�e (from confractar invoict�): $,��. �s�'� �` <br />F'I�a�� a�rify tta� ioliowrng: <br />am #he owner of the property where #he backwater preventicsn device was install�d. <br />�iworked with fhe cantractor to determine the lacati4n for the backwater pr�v�nfiian device and <br />underst�nd fhat the decision regarding the location af the device was mine. <br />�1�iy contractor instructed me how to access, inspect, and maintain the device. <br />ndersia�d tha# 1 am respr�nsible for maintaining the backwafier preuention device ana keeping <br />i# in good w�rking order, unless it is installed in the city right-ofi way. <br />! I se11 my praperty, I wil! make potenfiial buyers aware of the backwater prevention device and <br />the need to inspect and main�ain it on a regular basis. <br />am enclosing all of the necessary paperwork (use the yeltowr Rebate Submittal Checklist). <br />S�lect from th� following: <br />�J The contrac�t�r iden#ifiied downspouts ar other drainage Ilines that were connected to my �ewer <br />line {between my hause and the installed device) and removed, or rerou�ed #hem. <br />❑ To rny knawledg�, my prc�perty has nc� ciownspouts or other drainage connected to my sewer line <br />(betuu�en my house an8 the inst�alled device)- <br />�,..,� <br />e�e are dciwnspouts �t� other drainag� lines conn���ed to rny sewer line (between my house <br />�nd the installed device). I understand that I�aving thes� �ann�ctians creates a risk of flaoding <br />and 1 accept that risk. <br />:," <br />Sig�tafur-e ''} Aat� � f� �..�� ��,� � � � � - <br />� � v <br />