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��IY�If1t7Sf���Br o 6���U E�N�9ll �1v'fJ' HNfl� ���S6W�r �B &g��6Zltl 70 <br />�, �e���� ����a�a���� ���� <br />Praperly Owner Name; ���.f'� �. 1c 1'SYl I 1.�t r� � <br />Instaifatian Address: c� `1�-? t G'� -�-'.�' �� ��t�` <br />� �� � <br />Ciiy: ��,��,'.X�-�-'�.�. Sfiat�: Zip: �,� <br />Mailing Address (if differenfj: _ .��7_ % _�f�l`((� /�t P �/l � • <br />C[ty: � ` Statea trv ZiP: �3 , <br />Emaif: <br />li C C� �L � Phone: �j ?S CC �' `����� <br />Tot�l Cosf to lnsialI Device (from coniractorinvoic�): $ ��'T��'�� <br />Pl�ase veri� ��e� ���tovuirag: <br />� 1 am the owner of the prpperfiy where fi�e baGlcwater pre�enYiarl device was ihsfaiEed. <br />❑ E worked with the contracfor to determine ihe locaiian for fhe backwater prevention de�[ce and <br />undersfanci fh�t,fhe decision regarding the lacatian of fhe device was mine. <br />❑ My conti'actor insffucted me how to access, inspect, and maintain the device. <br />[] i understand that I am res�ansible for maintaining t�e bach7nrater prevertfion devic� and keeping <br />it in good worlcing order, unless it [s installed in ih� city right-af-vJay. <br />❑ If ! sefl my praperFy, I v�riii make potentiai buyers aware of the bacicwater prevention devlce �nd <br />the need to inspect and maintain it on a regular basis. <br />[] ( am enclo5ing ali of th� necessary paperwark (use the yellaw Rebate 5�bmittal Checkiist)_ <br />Se�oc� fraen th� folio�u'rng: <br />❑ i"he confracfar'identifled dawnspauts or otheC dratnage ilines iha� were connecYed fo my sewer <br />ilr�e (beiween my hnuse and the installed dsvice) and removed, ar rerouted therrt. <br />,�To my lmowledge, my p;ap�rty h�s no downspouts or �ther drainage connect�d ta my se�ver line <br />,, �[�eiWeen my hause and fl�e ins��Iled device), <br />❑ Tk�ere .are downspnuts ar oiher drainage lines connecte� t� my sewer Eine (between my hottse <br />and the ins#allad cievice). I und�rs�and that leaving these connect3ons ere�tes a risk bf flaoding <br />ar�d E �ccept fhat rislc. <br />Sigcasr��aP� --- <br />���e � � � � <br />� <br />