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4E77. L3ackwater Prevention Device <br />Property (7wner Rebate Form <br />��Pfease verif� the following items: <br />�L I am the owner o( the property served by fhe side se�ver vahere the Backwater <br />Prevention Device was installed. <br />�1 worked with my contractor to determine the installalion locr�tion for the Backwater <br />Prevention Device. I understand that the finai decision regarding installation location <br />was mine. <br />If the Back�vater ?revention Device was installed on my property: <br />• I have been shown how to access, insEect, and maintain my device by my <br />contractor <br />• I understand the City will not maintain the Backwater Prevention Device. I <br />am exclusively responsibie te maintain it and lo 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 tc maintain it. <br />Choose ane of the following: <br />�1As of now, rny property has no downspouts or other onsite drainage that connects to <br />the side sewer upstream o( the installed Backwater Prevention Device. <br />or <br />❑ I still have downspouts or other onsite drainage thal connecfs to the side sewer <br />upsiream o( the insialled Backwater Prevention Device. I understand that leaving these <br />connections means fhat the risk of flooding from oownspout or onsite drainage remains. I <br />accept ihat risk. <br />Signature ' ii1n�1t1 h Date 3 � 5 <br />Page 2 of 2 <br />Revised 09l09/2014 <br />