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Backwater Prevention Device <br />Property Owner Rebate Form <br />'lease verify the following items: <br />am the owner of the property served by the side sewer where the Backwater <br />enlion Device was installed. <br />4I worked with my contractor to determine the installation location for the Backwater <br />frevention Deice. I understand that the final decision regarding installation location <br />s mine. <br />If the Backwater Prevention Device was installed on my property: <br />I have been shown how to access, inspect, and maintain my device by my <br />contractor <br />". understand the City will not maintain the Backwater Prevention Device. I <br />am exclusively responsible to maintain it and to keep it in good working <br />order. <br />If I sell my property, I will make the buyer aware of the Backwater <br />Prevention Device and the need to maintain it. <br />Choose one of the following: <br />4y'',j As of now, my property has no downspouts or other onsite drainage that connects to <br />Ithe side sewer upstream of the installed Backwater Prevention Device. <br />or <br />❑ I still have downspouts or other onsite drainage that connects to the side sewer <br />upstream of the installed Backwater Prevention Device. I understand that leaving these <br />connections means that the risk of flooding from downspout or onsite drainage remains. <br />I accept that risk. <br />Signature ;' &Jaw ",�4 Date ? b71 2-01•6-- <br />Page 2 of 2 <br />Revised 09/0912014 <br />