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F.YF <br />Backwater Prevention Device <br />Property Owner Rebate Form <br />'Rlcasc verify.tiie following items: <br />j`,�I am ;he owner of thc property seved by the side sewer �a�here the Eiar,���vater . <br />�Yrevention Device was installed. <br />�I worked �a�ith my contractor to detennine the installation localion for the [3ack�vater <br />i�r.vention Device I understand that the final decision regarding installation lor.ation <br />���as mine. <br />� IF the Ciackwater Prevention Device .vas insla9ed on my property. <br />• I have been sho�vn ho�v to access, inspect, and maintain my device by my <br />contractor <br />• I undersland the Cify will not maintain the Backe�aler Prevention Device. I <br />nm exdusively responsible to maintain it antl to keep it in good vrorking <br />order. <br />I` I sell my property, I vdill make the buyer a�vare of lha Back�vater <br />Prevenfion Devir.e and the need to maintain it. <br />�Cho`use one'of-the Followiny: <br />! As of now, my propi:r*.y ha:: n:� �'.o�.��nspouts or other onsite drainaye th,�: cc�nner,ts to <br />th , side se�ver upstream of ih�� ii�stalled Back�vatrar Pra��ention Device. <br />o� <br />[] I slill h�3ve duwnspouts or other onsde drainaye lhal connects to lhe side sewer <br />❑pslream of the instailed tiack�a�ater Pievention Device. I understand that leaviny ihese <br />r�onnections nu�,;ns th,d the risk of floodinc� from do�vnspout or onsite drainage t��m;u is <br />i :3cr,ept lh;�� tisk <br />.� <br />�, �,-.- � <br />/ ,� .= �' <br />, ,. ' , ,. <br />C.• ,-�.�"�, <br />Si nature'�� �.: <br />�� q LC�� F,_i�-<-ufT r <br />C: -' � . <br />Rcvised 09r�'cl?014 <br />Oate �/ !� /�C � � <br />P�,ae ? �` ' <br />