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Backwater Prevention Device <br />� ; � Property Owner Rebate Form <br />Piease vePify the following items: <br />� <br />`� I am the o�vner of the property ser�ed by the side sewer where the Backwater <br />Prevention; Device was installed. <br />�;.I workeU with my contractor to determine the installation locafion for the Backwater <br />Preventiom Device. I understand that the final decision regarding installation location <br />was mine. <br />,. ' <br />i�; If the Back�vater 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 />I understand the City �vill �ot maintain the Back�vater Prevention Device. I <br />am exciusively responsible to maintain it �nd to keep it in good working <br />order. <br />If I sell my property, I v,�iil make the buyer aware of the Backwater <br />Prevention Device and the need to maintain it. <br />Choose one oF the following: <br />�As of now, my property has no downspouts or other onsite drainage that connects to <br />the side sewer upstream of the installed 3ackwater Prevention Device. <br />nr <br />❑ I still h:�ve downspouts or other onsite drainage that connects todhe side sewer <br />upstream of the installed Backwater Prevention Device. I understand that leaving these <br />connec!ions means that the risk of iloodmg from dovdnspout or onsite drainage remains. <br />�ccept that risk. <br />�Signature�,?,tul�� �j�('.f� rDate =L_� %— �5 / <br />Page 2 of 2 <br />Revised 09109I201d <br />