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�', _ <br />�� <br />����� <br />� , <br />� r: � �': � "., s �:l�. M �' !t r <br />�`� �' i � ' � '� � � �:k M� �� . � ,>. <br />Praperty UwnerName: <br />tnstallation Address: � ,,� ����r���.,�_�� <br />City: . ���1�`��� State: _ ,�., —Zip: <br />Mailing Address (if different): <br />City: <br />Errr�il: <br />Stafe: <br />Total Cost to tnstall �evice (�iom cor�tracfvrinvoics): $ <br />Please v�rf�y fihe fallowint�: <br />Phor�e: ( <br />��, <br />� m the a�wner of ihe prap�rty where the backwater prevenfion device was inst�lled. <br />�worked with th� coniractor to determine the locafi�n for the backwater prevention device and <br />und�rstand that the decision regarding th� lacation of the device was mine. <br />�My,,..eontractor instructed me how to access, inspect, and maintain the device. <br />�understand that 1 am respansible for main#aining fi�e ba;ckwater prev�ntion device and keeping <br />it j� gaod working c�rder, uniess it is installed in the city righ#-ofi way. <br />� If i sefi my property, I wifl make patentia{ buyers aware af the backwater preven#ion device and <br />the need to inspect and maintain it on a regular basis. <br />�am encfasing ali af the n�cessary paperwork {use #he yellow Reb�te Submi�tal Che�klist). <br />Selec ,�ram the falEowing: <br />The con�racior identified dawnspouts ar t�ther drainage tlines tfiat were cnnnecYed to rny s�wer <br />lin� {between my f�ous� and th� installed d�vice) �nd removed, or rerouted fihem. <br />� my knowiedge, my prvperty h�s na d�wns�t�u�s c�r oih�r drainag� connected #o my sewer line <br />( etvueen rt�y hause and ihe install�� deviee). <br />Th�r�: are downspouts or other drai�age tine� cannected to my sewer line (between my iic�use <br />�nd t�t� installed d��rice}. t understand thai teaving khese conneciions creaies a risk c�f #iooding <br />and l accepk #hat risk. <br />� � .. f <br />�, ��,.w ' � ! <br />Sigrtafur' � Date <br />�� <br />