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€ <br /> � <br /> Ba�kwat�r Prevei�tion Device R+el�<�te Proc�r�n� <br /> � Rchate Ap�lic�tion Form <br /> � <br /> 1,�'r,,v',W--.' r-' <br /> Property Owner Name. . �.'�'���" � +��� � ���� <br /> installation Address: ,��c�� ��:���,��,��,.� �� � ;. <br /> City �;.tJ�a'��._�-' :�(,�tc� �-`� i'_iF�: ��;��� r. <br /> _-----._. <br /> l <br /> Mailing Address (if different): � <br /> City:------- -------- - ;�i<31c� Zi{:�:. � <br /> Email: F'I�anc.: ( } �: <br /> � <br /> To�al �ost to Inst�ll Device�(fr��rn r,<»�f��ir,t��r�'invnir.r;): n,o ��,�,��, `� � <br /> �. .._--__ _._..... ____--__._._ �:. <br /> r <br /> Piease verify the foltowing: � <br /> ,,, <br /> � � <br /> �'I am the owner of the property wlierc tlte 1�<��kwr�tt�r preverition devir.e was ni:;lallr�d ,: <br /> � <br /> [� f work'ed with tf�e corrtr�c#d� t� detem�in� t}���Ioc�tion�forthe���ckw���fE�rr E�rcv�:E�iti�7�a ti�.vi��.��:;�nri �` <br /> understand thaf ihe decision regardinc� tltc�Ir�c,�tic7n o(ll�e device w��s n�ine. <br /> [� My confractor instructed me how !o <�ccrss, insp��cl, zmci i7iainlair� the devic:c� �. <br /> [�I undersfand that ! am responsifale lc�r n��3ir�l;�inir�e� fh�.� b��ckwatc�r Ext�vc�nlic��? cir.v��:�� ;�nc! k��r.Enny <br /> it in good working order, unless il is inslallec� in thc� city ric�ht-of-way. <br /> If! sell rn ro ert ! irviil make ���l��rttial bu t�r5 �iwarc:�of ili�e ba�;kw<ai�;r }�r��vr.nli��n��-ii�v�cn ;an�l � <br /> C� YP P Y. t y< : ~ <br /> ', the need to inspect and maint,=�i�� il on �a requl�:�r t�asis. <br /> [�'I am enclosing all of the necessary pa�erwork (use lhe yellow Rehate Subn�iU�al (;ti�:c;klisl). <br /> Select from tfie following: <br /> ���J l"I�e contraclor idenfifii�d downsE�oi�ls s�r ofh��f ci��3inri�.�c� Ilin�es th���t wer<� c<�nri��clr.cl l��any ;�,�:wur : <br /> line jt�etw��n rr�y I�ouse and tFfe inst��ll�c���evice) ���nd r�xi-noved, c�r ��:rz�c>tile�l tl��;n� i <br /> (`�To r��ry kr�owfedge, my properLy�I��s nc� d{��vris��mi�ls t�i o[hei clr;�siat<����; cr�nn��c:l��Fi lra n�y�,r�w���� lin��� <br /> {E��>fwc��n my t�ouse and the inst��lieci cit.vic;c�). � <br /> � � �(�iorf: ;rrc �iownspouls c�r otf�tt�r �iitiiiri�7�� liifr,;,���nn��{;lf�ti !t� iuy ;;t�w��� lui�� (In,lw�����i iuy ln�u:;4� <br /> �inc1 Ihti ins(��Il�d�de�,vice}. i �mder�st<�n�i lli,if I��i�vint� (I��:s�: cc�nnc�;liun:; �,i��.ift�:�. .t r��,l� �,1 i!u{,�tinf� <br /> �3n�1 I <�t:c�;�>1 ihat risk. � . <br /> � <br /> � <br /> � � ����, � � <br /> Siqn�lurc ��-¢�� ,�'�� D�te � <br /> `.�--_._ � ��r�� t� <br /> _ <br /> . � <br />