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B��kwa�er �r�venti�n evic� e�a�t� I�ro�r�m <br /> ��a�te �plic��ior� Farm <br /> � <br /> i \ � ti` [ <br /> �Property�wner Name; ��� � ������� f�`I �•�1 <br /> Install�atian Address: ��(�_�,_ � �� ���'-Qi� <br /> City: L.. �$.��--� State:^ Zip: t ��� <br /> ! <br /> Maifing Address (rt'c�itferent): ��'LP <br /> City: Skate: Zip: <br /> , � � ,�+ <br /> Email:` �' C4.i � �. Phone: (��� �t��� �� ! �.'` <br /> Totai Cc�st tc�'Install d�vi�� {frr�m contract�rinvoice): $ �.`��L�;�t� <br /> i' <br /> Please verify th�following: , <br /> �I am the owner of the properky where f�'e backwater prevsntion device was ir�sfalled. <br /> � I worketl with the contractar fa deterrnine the'Cocatican for�he ba�l�v+rater prevention devic� and <br /> understand fhat the decision regarding the Ic�cation of the`device was mine: ' <br /> �j My contractor instrtacted me how ta �rccess,`inspect, and maintairt the device. ' 1'' <br /> f:understand that I am responsible for maintaining#he backwater preventian device and keepin� <br /> it in good working order, uniess it is installed in the city rigi�t-of-way. ' <br /> � ' "�] �If I se11 my prt�pe��a 1 willmake,potential bu}rers aware of�the backwate�p�eventian devie�e and <br /> the need to inspect and maintain it on a regular basis. <br /> �,,I'am enciasing ali of the necessary paperwork (use the yel�ow Rebate Submitfal Checklist). <br /> Select from tkie fall4uving: <br /> � The c�ntrac#ar identified downspouts or oth�r drainage Ilines�that were connected ta my sewer <br /> �line (b�tween my house and the��inst<xlled device) and removed, or rerouted them.' � � <br /> � Ta my know[edg�} my pr€�perty has no dawr�spoufi�rar oth�r drainage conn�cted to my sewer(ine <br /> ' {between my hc�use and the installed device�. <br /> ❑ There are downspauts or t�ther dratnage lines connect+�d t€�my sewer line,(between my hause <br /> and the installed device). 1 understand that leaving these conne�tians Creates a risk of ffooding <br /> and,l accept that risk. <br /> � <br /> � <br /> Signature � Date �' <br />