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'i��i��'�[�D�C�I� <br /> l� Nov u t zo�y <br /> Backwater Valve Installation Program <br /> E Installation Authorization FarmL'I-`� ��� �}��'S <br /> 1 Permission b Insoect. The Owner grants permission to the City and rts contractar to <br /> _inspect the ptumbing.and,dramage.of.the.O�vner:s.property_for:he.purpcse.of <br /> dctermining whether a backwater valve should be'installed The City and Owner will � <br /> cooperate to determine a mutualty agreeable lime for the inspection. The inspecLon <br /> is ar the City's sole cost <br /> 2 Backv✓ater Valve Installation The City will review the results of the inspection and <br /> ��nli determine whetfier a backwater valve should be installed By signing this <br /> authorization form, the Owner grants the Ciry and its contractor permission�to install I <br /> th�e back�.vater valve if the City determines that a bachvater valve should be installed <br /> 1 his installati^n is at the City's sole cost. <br /> � 3 �ite Drainaoe �� inspection of'he property identifies that there are do��nspouts <br /> connected to the side sewer �pstream oi the propused backwater valve locat�on, the <br /> downspouts will be disccnnected or re-routed do:�mstream of the backwater valve <br /> By signing this authorization, the O�vner grants the City and its contractor permission -I <br /> to access the O�vner's property to modify drainage connections. Drainage <br /> �-�oditicaLor �� at ihe City s sole cost _ __ _ <br /> OWNER�S►: <br /> .-. <br /> i / <br /> � �.n��- / _ �-_ - — �� -- <br /> Signature Signalurc <br /> �'VIQ �I��_ G AY�1�— -- C ( �S / '_�A�� . <br /> Pnnled NSme Printed Name'. <br /> �"lZ2 �i'�YLtI'W� -�VZ --- - — <br /> Pnr,ted Address Date <br /> � Phone Numbcr Emad <br /> I <br />