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Backwater Prevention Device <br />Property Owner Rebate Form <br />Please verify the following items: <br />[� i am the o�vner o( the property served by the side sewer vrhere lha Bar.k�vater <br />Preventiun Device vdas inslalled. <br />� worlced �vith my coniractor to determine the installation location for the Backvaater <br />Prevenlion Device. I understand that the final decision regarding installation location <br />was mine. <br />[a I( the Backwater Prevention Device v✓as installed on my property: <br />• I have been shown how to access, i�ispect, and maintain my device by my <br />coniractor <br />• I understand the City �vill not maintain th.e Backwater Prevention Device I <br />am exclusively responsible tu maintain it and to keep it in c�ood working <br />order. <br />• I( I sel! my property, I v�ill make the b�yer 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 connecls to <br />tlie side .>ewer upstream of the inslalled Backwater Prevention Device. <br />or <br />❑ I stili have downspouts or other onsite drainage ihat connects to the side sewer <br />upstreairi of ihe installed Backwater Prevention Uevice. I understand that Ieaving these <br />connections means lhat the risk of flooding from doNmspout or onsite drainage remains <br />I acr.epl ihat risk. <br />�� cx� n <br />Signat rh e5_/ i.c.�u �'� � Q�-%"t Date�(7 /j <br />f <br />Page 2 of 2 <br />Revised 09(09/2014 <br />