2619 ROCKEFELLER AVE 2016-01-01 MF Import

BACKWATER PRE�/ENTION DEVICE FINAL INSTALL�ATION CHECKLIST �Ail Z C�nf/acf0�5, LLL �. Installation Company Name and Contact Info: �ic �x� �(�1 c/q � 360 • 39l -�75/ 'Ioe 2/a b�`376 7305 Date Bac!cv,ater Prevention device (BVJD) was installed��N �`�u ��-5 yO�bele this torm was completed: ��- �- �� Instaliation Prop�:rty O�vner Name and Contact Info: Sy�n Q-Z�'� �`f Z5 '�!i-67/i PropertyAddress: ��19 /Lu�lctfi'/�t'�A�'-� �v�Pfl (✓� ��'�C�I Pre•Installation Inspection Checklist: Al! items must 6e checked 'Yes' in order (or a BV✓D fo be considered (or installation Is there a basemenl or level of the house thal is at or near as;umed sewer main elevation7 � Yes ❑ No Are lhere fixtures in lhe house !o�;ated below the upstream sewer manhoie rim elevation? � Yzs ❑ Uo Is �he side sewer currently UNPROTECTED from sewer backups (does nol have a BWD installed)? �Yes ❑ No Sit� Inspection Checklist: All items musf be checked 'Yes' 6e%re inspection is consrdered compfete Was side sewer TV inspected from buildirg lo sewer main? � Yes ❑ No Condition: d K Does side sevrer have al least 1°b siope from the building to se�ver main? � Yes ❑ No Describe: 2°� Have all build:ng sewer drain conneclions to lhe side sewer been identified and localed? � Yes ❑ No Have all proper�y storm drainage connections to the side sev�er been identified and located? �Yes ❑ No Has property been evaluated for d�ainage deFiciencies �vilh tindings communicated to propeRy owner? L�Yes ❑ No Installation Details: What rype and brand of BWD �vas installed al this sit Clean Chec WV, Grinder pump, etc.): �'�PM Glivc�c Y�� Where �vas the device installed (general description, altach map)? M QP �i ��ti� p�� /Uc�ri�,.- �v-Ph e f ( c,t- n� c� ti 7' da S e i,.re/' m<t 1 � r� rup. N'as there any other sewer or storm drainage work compleled in conjunction �vifh lhe BWD work7 Is so please describe: _ Installation Checklist: Are ali downspouts and site drainage disconnected from upsiream of the BWD? � Yes ❑ No Comments: Does BWD positicning meets minimum slope requirement of >t%? � Yes ❑ No Commenls Can BWD be pulled out (or inspection and maintenance afler loosening thumb scre��a? � Yes ❑ No Is BWD locked into the proper position and thumb screw tightened? Q Yes ❑ No Circle lhe BWD cove irri ation cove landscape area j traffic load bearing cover {drive surface) i access hatch (building) Was property owner shown lhe location of 1he installed BWD? [3�j Yes ❑ No Commenls: Property Owner's Signalure: N�/Gi.l�tJ%l� �l�r Date: �/-b "lS Installer's Signature: Dale: //-- d�� S— i Revision:: 1 Friday, September I2, 2014