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0 <br /> r�n����� V �(1 <br /> lJ� OCT 2 1 2014 U <br /> Backwater Valve Installation Prog�,r�rSLIC VJ�IZKS ' <br /> Installation Authorization Form <br /> 1 Permission to Inspect The Ovaner grants permission to the City and its contractor to <br /> ;nspect lhe plumbing and drainage of the Owner's property for the purpose of <br /> determining whether a backvrater valve should be installed. The City and Owner vnll <br /> cooperate to determine a mu'ually agreeable time for the inspection The inspection , <br /> �s at the C�ty's sole cost. <br /> 2 Backv,-ate� Valve Installation The City vaill review the results of the inspec6on and <br /> will determine whether a backwater valve should be mstalied. By signing lhis <br /> author�zation torm, the O�vner grants tne Ciry and its contractor permission ;o install <br /> ihe backwater valve if the City determines that a backwater valve should be installed <br /> This installation is at the City's sole cost. <br /> 3. Site Dramaqe If inspection of the property identifies that there are downspouts <br /> connected to the side sewer upstream of the proposed backwater valve location. the <br /> downspouts�vdl be disconnected or re-routed downstream of the back�vater valve <br /> By siyning this authonzation, the Owner grants the City and ds contractor permission <br /> to access the Owner's property to modify dramage connections Drainage <br /> modification is at the City's sole cost <br /> O S�: <br /> �.� �-�. , �- ' _ <br /> Sgnature. � Signa ure. <br /> —Dctvi�}�ur� �E' . �`{/—�� . ` t,tl' Z <br /> Pnnted Name� Prinled��e! <br /> 15 I `� 6 r�a rsl �-1Ve- lo I � I �( <br /> Printed Address Date <br /> �Z 5 -Z59- Z�Lo 8'� ���(�,�f�_��P. ( o vt� <br /> Phone Number mad <br />