Laserfiche WebLink
Backwater Valve Installation Program <br /> Installation Authorization Form <br /> 1. Permission to Insoect. The Owner grants permission lo the City and its contractor to <br /> inspecl the plum6ing and drainage o(the Ov:ner's prope;ty for the purpose oF <br /> determming v:hether a backwater valve should be ins;alled The Gty and Owner will <br /> cooperate to determine a mutualty agreeable time tor U,e mspection The inspeclion <br /> is at the Cdy's sole cosl <br /> 2 Backwater Valve Installation The City vnll review the r=sults oi the mspedion and <br /> wiil determine whether a 6ack�va;er valve should be installed [3y s�nmg this <br /> authonzation form, Ihe Oe+ner grants the City and ds contractor permission to install <br /> the backwater valve if the City determines that a backtivaler valve should be Installed. <br /> This installation is at the City's sole cost <br /> 3 Site Drainaae If inspection of the property identifies that there are do�+�nspouts <br /> connected to the side sewer upstream of the proposed backwater valve location, the <br /> duwnspouts wiil be disconnected or re-reuted downstream of the backtivater valve. <br /> By signing this authorization, lhe Owner grants the City and ds contrector permission <br /> to access the Owner's property to modrfy drainage connections. Drainage <br /> rood�fi�_alinn is at tha City's sol? cosi <br /> OWNER(S): <br /> Si"g�iature ���L�� --- S�gnaturc: -- — -- <br /> Printed ame ����� Printed Name <br /> ����.s����s��_ �� _�.�ahr�+,---- � <br /> -- -- -- <br /> PrinledAddress Ly� �ZGGj Date <br /> ' Oo S-?4'�' <br /> '14 9 (n4s (� 3�d�1 _Liu 149 - - -- --- <br /> Phone Number [mad <br /> ��OR�n= al i`112 � R.aN�j �YE, �VG-n.,6�T �S 4 R.6N�PL . <br /> ��nPNP. C�EA 3y 1_�aw� ourL � �X �n.-oPt2z-�c5 , <br /> P��Ase �-O ��L� � Ati'� Q C..A�t.� ov2cJY 7e c.�pn.o �Al <br /> �n�/ 2 F nl i E �LS <br /> oFe=�e.c' � �I2S' zs q 17 � 4 <br /> O (l SAbr �;' 4z1' L2z OrlGN <br />