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�o ����o�� � �' <br /> U �1 NOV 2 6 2014 <br /> D <br /> Backwater Valve Instaliation Progr�ri��L(C WORKS <br /> Installation Authorization Form <br /> " Permission to Inspect The O�rn�er grants �ermission to the City and its contractor to <br /> �nsoect the plumbing and d:airage cf the O�vner's property for the purpose o� <br /> deterrnin�ng whether a backwater valve sl;ould be installed The City and Owner will <br /> cooperate to determ�ne a mutualty aareeable time for the inspection The inspechon <br /> is at lhe Cdy's soie cost <br />` '' Backwater Valvz Installation The City ��rill review the results of;he mspeciion and <br /> � <br /> wiil determine v.hether a backwaler valve should be installed By signing this <br /> nuthonzation form, the O�.vner grants Ihe City and its contractor permission to install <br /> the back�vater valve it the City determmes that a back�valcr valve should be installed <br /> This installaUon is at the City's sole cost. <br /> 3. Site Drainaae If inspection o�ihe prooerty idenhhes that 1herP are downspouls <br /> connected lo lhe side sev�er upstream of the proposed backwater vaive location. the <br /> dcrdnspouis���ill be disconnecled or re-routed dov;nstraam o(the bachv ater valve <br /> E3y signing this authorization, the Owner grants the City and its conlractor pem�ission <br /> to access the O�a�ner's property lo modi}� drainage ccr.nections Draim��a <br /> medif�r2fi0� Ic 2I �h@ CIIV S $OIE COS} <br /> OWNER(S): <br /> �'� ; <br /> � � - <br /> Signa ure Signature — --- <br /> ���•.�-r�rrs•_�: - -- — <br /> Pnnte� Name Pnnted Name <br /> �.J�G j �.Z^l'c..�c� 0`,V-2 <br /> �- —-- - —. . . <br /> Pnnted Address Uale <br /> ZQ�-.�i?'�-'�Z�l�i-- - - - -- - --- '- <br /> Phone Nuciber Finail <br />