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Backwater- Prevention I)evice Retr.it�� Prc�yr;�m <br />=tv�T, Rebatc A��plicalion Fon�� <br />Property Owner Namc �%f[f�Ltr7 �L�� <br />Inslallation l�ddress: j�9 �/ -��,—yZ-7,��-L �-�/�r <br />ciy: L-Z/�-�7 <br />PAoiling Addm;g (J/ Uil(rrpidJ. <br />i.iiy. ---- ----- - - --_ . <br />Emad <br />:;i:d�� !-v f�" <br />:iLdc <br />�o��l Cost to Inslall Dc'✓iee (Iruqi rrur7inr.lui rnvurr.c/ ;, <br />I- — <br />: ��,� Q�7�' I <br />Zlp. <br />Phonc: ( ) <br />3,(� �o, O� <br />Please vcrify the following: <br />I� I am the owner of lhe properly whe:e Ihc bac;w,alci prcvention davir.c vr,c; IIIG�.IIILII <br />�f I worked with Ihe cunlractor lo dcicrnwic Ihr locntion lor Ihr. bar,kw:Ucr preveidic:u dcvu:e ;uid <br />undeist��nd that Ihe decisinn regarding Ihc lor,ation of Ihr. devicc �va�: rnin�e <br />(�� MY r.ontracla inslrucled me huv� (n ;ir,a:ss. ins�ir:r.l. �nd m;tinfaii� Il�rr dr.vir.c <br />(�'j I undcrsland that I�rn respunsibi�� fur m,wil,iining 1hc b;u:kwalcr pruwrnhun dcvu �::ui�l k��i��uny <br />it in good working order. unless �I r; iiisl,dled in Ihe ci�y nghi-of.way <br />(�� If I scll nry property, I�vill makc pofcnU;d buyr.r.: aw�au: o( Ilic b�cF:v.�nlu; picvcnlinn d��vir.c ;ind <br />the need to inspec( and rrainfain il on �i re��ul�r basr <br />�� I am enelusing all o( fhc ncr.essary p:�pr:wo,k lu:,e Ihr. y�llow Rchalc Sabmitl;d Chrr.klr..l) <br />Seled tram thr. (ollowing: <br />� � The conlraclor idenlified downs�muls ur ollnv drun,iyi� �line:: Ili.d wciu runn��� le�l lu niy •:cric� <br />line (t�elween my hou;r. and thc in�:lallr.d dr.vicr.) ;uid removeci, nr n,ruile�l Ihwn <br />��� To a�y knovAed�e, my pioperry luc; nu du�rm�.puuls oi c�ihei dr�unn��c i:niuu•r.t�r�l in niy •.cwri luur <br />(belween my house and U�e in�:l:dlc�l �luwcc) � . <br />� � Ilicicnrcdot•mspotd,urothc�di:un:u�clnirsr.unnccicdluniy,.;cv:cihn�:(In•Ivn��•uniylinic.i• <br />nivi thc inslrilled dewr,C) t undcisl+mil Ilcd Ir:rvirn� Ihr:,c r.unnt•r.hun, � ir.dr�. ,� ir.L �d tl��u�!in�� <br />nnil I ;icr,rpl (haf risk <br />� <br />s,����.,r,,,�, --- •-� <br />n,,�j(I1 �� <br />