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G ��� �°�V �1 V1� ��"� � <br /> �. ����� ��� �Q � <br /> Property Owner Name: �� w[ `'�" --�Y��`���� �'��lr�` ����r`"`� �� <br /> Installation Address: t°°����� ����� �� ��� <br /> City: ��t'_�.�,�>�, State: �„���� Zp� ��-�� ; <br /> Mailing Address(if different�: �� <br /> City: State: Zip: ' <br /> Email: ���(�l�' ����t.���' �1(�1`�`1��..� +���Y�°F�hone: �-��� � '"r�:��% <br /> /� C, i. <br /> Tot�l Gost to tnstall Device (from confr�c�oriRvoiee)_$ `�-1-(�,��1� <br /> ;. <br /> Pi�a���€�ri�t��foOlo�nairac�: <br /> �{ am fhe owner o�fhe property uvhere the backvvafier preven�ion deWice was installed. <br /> �i worked with the contractQr to defermine the lacatian for the baekwa#er preuenfion devi�e and <br /> undersfand that 4he decisian �egarding the loca#ion of the device was mine. <br /> ❑ My contractor instructed me how fa access, inspect, and maintain the device. <br /> ❑ 1 understand tha�I am responsible for maintaining#he backwafer prevention device and keeping <br /> it in good working order, unless ifi is installed in the city right-of-way. <br /> �lfi I sell my properfy, i wiiE make potentiaf buyers aware of the�oacl�vva4er prevention device and ' <br /> the need fio inspect and maintain it on a regular basis. <br /> ❑ I am enclosing all of the necessary paperwork{use the yellow Rebate Submi#�al Checklist). � <br /> Selec�ft�z�rn�i��#ollovuing: <br /> ❑ T'he contractar identifi�d downspou�s or o4her�rainage Ilines that were connected to my sewer <br /> line {between my hause and;the installed device) and removed, r�r rerotrted them. <br /> [] To ti°iy kr�owledge, my prcaperiy has no downs�auts or�ther drainage connected fcr my sewer line <br /> (befiween my house and the installed device}. <br /> [] There are downspouts or other drainage lie�es connecfed fo my sevver iina(befween my house <br /> and the installed device). i �nderstand that leaving these connecfions cre�tes a risk of flooding <br /> and ! accept that risk. <br /> �i��a��ua� �-=�',�' �"���'��,�. D��e �-� �.�� �_ . <br /> , � <br />