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J�: :. . ` s �,� - `-i. � ` •� .� <br />�"-•.`. .. �.s. . � � <br />� <br />Property Owner Name: (V'•� � r-1-(.r������(�--� �.GiL�U (,�.� ��- L��!'"V <br />Insfallation Address, � l�� �°�'��'���r�- i��-� <br />City: ���� State: � ' Zip: � �� � <br />Mailing Address (rf different): ��� �.� f.�-VJ�-�-�� <br />City: <br />State: <br />Zip: <br />Email: ���� Phone: (� ���' `` �°`t ( <br />��� <br />Totai Cost to Install Device (from cor�tractorinvoice): $ �;;'�j�"� "'"`��� <br />_ __ <br />Please verify the follawing: <br />t i am the owner of the property where the backwater prevention device was installed. <br />� worked with the contractor to determine the location for th� backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />[i%f My contractor instructed me how io access, inspect, and maintain the device. <br />j�l understand that I am responsible for maintaining the backwater prevention davice and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />�] If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it an a regular basis. <br />�I am enclosin all of the necessar a erwork {use the ellow Rebate Submittal Checklist} <br />9 YP P Y <br />S�I��t from the fallowing: <br />❑ The contractor identified downspouts or other drainage ilines fhat were cannected to my sewer <br />'ne (betw�en my house and the instal{ed device) and remaved, or rerauted them. <br />To my krrowledge, my properfy has no downspouts or other drainage connected to my sewer lin� <br />{between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer lin� (between my hfluse <br />and the installed device}. I understand that Ieaving these connections creat�s a risk of flooding " <br />and I accept that risk. <br />� <br />Signature ��!�� Date ���--� � �� <br />