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Backwater Valve Installation Program <br /> �. Installation Authorization Form <br /> 1 Permission lo InSpec, The Owner grants pennission to the Cdy and its contractor to <br /> inspect the plumbing and drainage of the Owner's property for the purpose of <br /> tletennining whether a back�vale valve ;Foul� bc �n;tall�d The C�ty ard O;:ner ::ill <br /> c000erate to detem•ine a mctua. y �cro�ahle tnnr for tha �nspection The inspection <br /> is at the City's sole cosl <br /> Z Qac4�:�ater Valve Insta lat,on T!ie Ci;y v:ill rewe:v lhe resul,s of the inspeclion and <br /> �vill determine v�hether a bac�:v:ater valve snould be installed By signing ihis <br /> authorization form, the O�.vner gran;s the Ciry and ds contractor permiss�on to install <br /> the backwater valve rf the City determines that a back�vater valve should be msta�led <br /> This mslallaf,on is at lhe City's sole cost <br /> 3 Si;e Dramaqe It inspection of the property idenLfies that there are dovmspouts <br /> connecled to the side sewer upstream of the proposed backwater valve location, the <br /> do�vnspouts w�ll be disconnecled or re•routed downslream of lhe backwater valve <br /> By signing this authorization. the Owner granis ihe Gty and its contractor permission <br /> to access the Owner's property to modi'y diamage connedions Dramage ' <br /> modr'�cation is at the City's sole cost <br /> OWNER(S): <br /> � � i�i <br /> �1 - �,��y_"�,�f' '"'� _ <br /> Signature: Si�na�ure. <br /> li��ce �k 1o ��,su� SueS�Yve"� ��� ��_�:,5._%� <br /> I�unted Name. Pnnted Name: <br /> ��{��O Gf0.n� f1U� �U �d�/ a.oi�� <br /> Pnnted llddress Date <br /> ���u ��l a4J� - — SuzSl-A4f(� I�o� n�a� � , Cvm <br /> F'hone Numbci- -- Email <br /> ������M� ; <br /> o�� �e .. . �D� <br /> . P�$LJC WpRICS <br />