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Backwai:er Prevention Device <br />Property� Owner Rebdte Form <br />Please verify the following itein;: <br />��✓:�i am lhe ewner of the property sirrv��d bv liie s�de so�r;:�i �,vliere th�: 6;�ck���eter <br />F��evention Device was msta"cd <br />�� ��dorked with my conirar,lci to �1�.t�-nnine U��e �n;lallalion I��cntion for tne d,�ck�.�a;er <br />�'rE:vantion Device I understand tf�,�! tl�e (�n;il decision regardiny install,;tion 6;�ca'ion <br />�•,-as mine. <br />!:-, I` tf.e 6;�ck�•�ater Prevention Device v�-as installed on my property <br />• I IlE3VB �C'P.11 SIIUN'fl f10W to access, inspect, and maintain rny d��;vir� oy in; <br />contracte, <br />• I understand the City v+ill not maintain the Eiack�vater Prevention Device I <br />am exclusively responsible to maintain it 2nd to keep it in good �vorkinq <br />nrder. <br />• li I s�il rny properfy, I �vi�l make the huyer a��;are of lhe Ba;:k�•�;;3tur <br />Prevenlion Uev�ce ard the need to maint :Ic it. <br />cChoose one of.the followiiig: <br />, <br />��� I�s o' no�v, niy prr�perty has r,o r1n�;�n���r�uls or Ut�2r onsde �r,:inaye iha; conr,erf� f� <br />U�e side ;�-�r;er u��s'ream oi lhe inst,311�t�! L3�acKr:ater f�ievention Device. <br />ui <br />�� I stiil have cov�nspouts or othe� onsite drair��ge lhal conner,is t�� ih;� sidn s���,cer <br />u���,tream of the installed Hack�,voter Prevention Gevice I�mdeist:in�i th,:f Ir:ivinq t`iesr <br />curnectians ir�,,:aiis that th�� i�sk a`, flp�iding (roni i?rn•✓nspr.ut oi onr�ito druna�gc� r�tino�ns <br />I ,ia:eol ,h;it � r;N, <br />,: —��. - <br />Signaturc LLr�.,;�:�..�`�� /r� �' r7-,_�-- _ rDatc _. .l�l !���'��'�.1 - -- <br />�!�-=. <br />F.�9e 2 u! 1 <br />f.'a,.s.,;1 C;q,����r.7���� <br />