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J <br /> j�������IC�D <br /> IUl:"I Z 1 2014 <br /> � Backwater Valve Installation Prc�gram`�g? iC V4'ORKS <br /> Installation Authorization Form <br /> 1. Pennission to Inspect. The Owner arants permission to the City and ds contracior lo <br /> inspect the plumbing and dramage of the Owner's property tor the purpose of <br /> I determlrnng �vhether a backwater valve should be �nslalled The City and O�vner v+ill <br /> cooperate to determine a mutually agreeable time for the inspection The inspection <br /> iis at the City's sale cost <br /> 2 Backwater Valve Installation The City will review ihe resuils of the inspection and <br /> v:ill delermine v�helh=r a backv+ater valve should be installed. By signing this <br /> authorization form, the Owner grants the Cdy and ds contraclor permission to install <br /> the t;ackw�ater vaive if the City detem�m�s that a back�vate� valve should be installed <br /> This �r,slallation is at the Cdy's solc cosl <br /> 3. Sde Drainaqe. If inspection of the property identifes that there are doe:nspou•.s <br /> connected to the side sewer upstream of the proposed back�vater valve locat�on, tne <br /> downspouts will be disconnected or re-routed dovmstream of the backv,�ater valve <br /> By sign�ng lhis authorizahon, tha Owner grants the City ano its contractor oermissicn <br /> to access lhe Owner's property to rnodif�� d��inaye c�nnections Dramaae <br /> m�drfication i, a� the City'S so�e cost. <br /> OWNER(S): <br /> . <br /> I� �� ��� <br /> l ,.1. -- `:"-�-{ �`_ P.�..,,s•-,-, — <br /> Signature Signalure: <br /> t�L��.y�, 12��se',1 C_0.rc I E . Pere:r:,er� — <br /> Pnnted Name --- --- Printed Name <br /> I �SZ`�' �� � �+Ie.e•U�-- �D_�9 20 �� <br /> Pnnted Address n��� <br /> ��2Sb-2l bp c'r��.�5e.�2.ao �@utsN.c o�n <br /> �hone Nwnber Ci*ia�l <br />