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Backwater Prevention Device <br />Property Owner Rebate Form <br />Ptease verify the following items: <br />�am the owner oi tlie property served by the side sewer wl�ere the Back�vater <br />Prevention Device was inslalled. <br />�'I worked with my conlracior to delermine ihe installation location for the Backwater <br />Prevention Device. I understand that the finai decision regarding installation location <br />was mine. <br />�f the Backwater Prevaniion Device �a�as installed on my property: <br />• I have been shown how to access, inspect, and maintain my device by my <br />contractor <br />I understand the City will not maintain the Baclavater Prevention Device. <br />am exr,lusivcly responsible to maintain it and to keep it in good working <br />order. <br />• I( I sell my property, I wiil make the buyer aware oP lhe Backwater <br />Prevention Device and ihe need to maintain it. <br />Choose one of the following: <br />[� s of now, my property has no downspouts or other onsite drainage that connects to <br />the side sewer upstream of the inslalled Backwater Prevention Device. <br />or <br />❑ I slill have downspouts or other onsite drainage thal connects to the side sewer <br />upstream of the installed Backwater Prevention Device. I understand that leaving these <br />connections means that the risk of flooding from downspout or onsite drainag� remains. <br />I accept lhat risk. <br />� �u�,��,�, , �I,� <br />Signaturc u �u , %��e+��� Oate a <br />Page 2 ot 2 <br />Revised D9/0912014 <br />