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�/� .,- <br />� : ,. <br />� <br />.: . `' � r�� � ! - ' - :�- �. `' s. �: ,. , <br />'' � .,°� `.� � .�. ': �. � <br />Praperty �w�er Name: � ����h'r�' �T� ✓r✓ <br />Installation Address:�� ��f'`f ��Y7 ��� <br />ciry: Ets�-7�7`% <br />Maifing Address {if different): <br />State: G��i Zip: ��� <br />City: State: Zip: <br />Email: d✓r�Y�� � �i�i'1�o . ��� Phone: (�flsj �%��f �-� 3 �._.- <br />Tatal Cost to lnstall Device (irom contractorinvoice): $ �`I '.� -� <br />P9ease verify 4h� fo9lowi�g: <br />[�1 am the owner of the property where the 6ackwater preventian device was installed. <br />[�I worked with the coniractor ta determine #he location far the bac4cwater pre�entian device and <br />understand fhat the tlecision regarding #he iocation of the device was mine. <br />[�My contraciar instructed me how ta access, inspect, and maintain the device. <br />[�I understand that I am responsibte for maintaining the backwater pre�ention device and keeping <br />it in good working order, unless it is ins#alled in the city right-of-way. <br />((]�If I sefl my properiy, [ will make potentiai buyers aware of #he backwater prevention device and <br />[�Ihe need fo inspect and maintain it fln a regular basis. <br />am enclosing a11 of the necessary paperwork {use the yellow Rebate Submittal Checkfist). <br />Selec� fra�va th� following: <br />❑ The contractor identified downspouts or other drainage flines that were connected to my sewer <br />li e{between rny house and the installed device} and removed, or rerovied them. <br />�a my knowledge, my property has no downspouts or other drainage connscted fo my sewer line <br />(�etween my hause and the instal[ed device). <br />[] There are downspou4s or other drainage iines connected to my sewer line {betv+reen my house <br />and the installed device). I understand that leaving these connections creates a risk of flaoding <br />and 1 accept that risk. <br />Spgnatae�� � � � Da#e � �--/5�-�ll <br />