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4T,. BACKWATER PREVENTION �EVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contacl Info: <br />Da;e Back���ater Prevention device (BWD) was installed: � <br />=� Date this (orm was completed: �' o�= <br />Installation Prope�ty O�vner Name and Contacl Inio: Kav HOL�ENseCK <br />PrOperty AddteSS: 3702 ROCKEFELLER AVE EVERETT WA 98201 <br />Pre•Instaliation Inspection Checklist: <br />AII items must be checked'Yes' in o�der for a 91N0 to be considered for rnsfallation <br />Is there a Basemenl or level of ihe house ihat is at cr near assumed se���er mam elevatioc? Yes o <br />Nre ihere fixtures in the house loeated below the upsiream sewer manhole rim elevatio CKes , N <br />Is Ihe s�de sewer currenUy UNPROTECTED from se�ver backups (does nol have a BWD instalied ? CKe o No <br />Site Inspection Checklist: <br />Alf rtems must be checked'Yes befoie inspecfion is consrdered comple(e <br />Was side sewer TV inspected from buildina to sewer main? Yes 'o Conditiore <br />Does side se�ver have at least 1% slope (rom lhe building to sevaer mein Yes I No Describe: <br />Hzve all building se�ver drain connections to ihe side seiver heen idenlitied 2nd located� U' s� No <br />H2ve all pro�erty storm drainage conneclions to ihe side sewer been identified and located . n Yes o� <br />Has properiy been evaluated for drainage deficiencies with findings ccmmunicated ro property owner. Yes I No <br />Installation Details: <br />INhat type and brand oi B�ND was inslali�d a1 this site (Clean Check B4VU, Grinder pump, etc.): G`�G� �d- <br />41'here was ihe device irstalled (general description, atlach map)7 '��� ���— <br />l4�as there any other se�ver or storm drainage work completed in conjunction with the BWD workl Is so please describe: <br />—� -- <br />Instailation Check!ist: <br />Are all downspouls and sile drainage disconnecled irom upstream o( le WD? � Yes �o Comments _ <br />Ooes BWD positioning meets minimum slope requirement of >195? Ye � No Commenls: <br />Can BIND be pulled out for inspection and main:enance aiter ioosening thumb screw. I`Ye CJJo <br />Is BWD locked into U eLQasiiicm�rtd-Fhu ib screw tightened. Yes No <br />C�rcle Ihe BWD coae irrigation cover (lantlscape area) fraific load bearing cover (drwe suriace� I access halch jbuitdin�) <br />�Nas property uwner shown lhe location of the inslalled BWD? n Yes I I No Commenis � � <br />\ r/V'roperly Ovmer's Signa re, � �=G' �`��"""�`�t Date: ��� / <br />\!J ���_��.!�� f <br />InstalleisSignature: (��-vo4`"—�t� Date: '�'�—.__�L="�S <br />Revis�on. 2 1 Monday, Sepleinber 15, 2014 <br />