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Backwater P�revention Device Rehat� Program <br />R�bate Applf�ation Fa�rn <br />Prapetty ��vnet Name� �CL�'�'1it �11'1(.�t:�i���'') <br />_ �— — <br />InsiailalianRtldros5_ ���(� �t ___ _ <br />c�iy� ��t.[,r� s��� 1,��!'- z�u ��'id J <br />Mailing Address {if differenli: _ � _ <br />CIty: �. _ _ StaJ�+. �ip -- - <br />Emad: ��_/ � �Q.i .�lI.W ,_ Phvnr jrQ't'1'3 J.i' $��'�b70 �t% <br />701�1 Cost to Insinll Devrce �trr�m cnmractnr in�-��r.e� 5_�C,�� 8.: �3 __ _ <br />Plcase verlfy tho follnwing: <br />� I am iho �3vncr ol fhc prapeRy vrherc the haclnvatrf �rr.r.�nlion CievICC� wfls it�sl�[led. <br />�t wa�FAd w;lh ihe cnniractor In datermine Ihe Iw:alion For Ihc bark�vatrr pievr.nlinn r]ev�u onii <br />�mriorsfand Ihai th� �iecis��n regardmg the location of ihe dovlce �v3s mine. <br />� 1\IM\tvly contrr��t[�r inslrucfed mn hcnv 1� access, insped, anr! mau�i�in fh� dev�ce <br />v�/j I undersl•�nd Iha! I ercm msponsi[fl� Tor ma�nt�mmglhe 6achwater prevcnl��n dowce And keepmq <br />d in gn�el w��ih�ng ort1eP. u�il��� d �s msi;�flad in Iho c�ty nght-oFw�y <br />�' [f i�r-ti my piopt�ny, l wiH m7kr pnlr.nliol huyeis aar�re ollhp I�ickwater pr�ventinn d�virr. and <br />tne neetl io inspect and ma,nL�1n it bn a mgWar bas�s. <br />US. I mm �ncir,=.ing nll �i ti�n nece�::ary p��ienvorF: lu�r� Ihr� yr.l�[rr� Reriatc S�i6mitlal ChccFlislj, <br />l-�y <br />Select from the follawfug: <br />�� TUo [ou[r�utor �d��}Idied down;peute or nflicr dr•�mnge tlmcs that +rmi[i c:t�nneti�ted Sa my ,evri�r <br />Un� (Getwc�n n�y huus� and 9he �nslaile!1 de�r�ce1 and remaved, or rrouf�d lhem <br />n'fc my kn�y�ir. d�r, my �raper�y Ito:� n� downspu�L� or ollttsr uir�ina{�c n��hrr,tc cl W tny &r_wui Ime <br />[Luttt•Qen my h�i�sn and lhn in�'.ta�11e�1 de�u;). <br />�?��crn ar� �luwnspnuls cr c�t�iPr r�rAu�yge lines conneciei� f4 my se�rr�r 6na tbet�va�n my iiou5e <br />antl iha fnslalled devfCc}. I undc�stanii 1ha( Icswng thesa cb(uteti�ans �tp5tes :� ri�k of flervJing <br />arid I acccpt l�tal ��sk <br />signarure ��� ._nare � �� ��__. <br />