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� <br />Backwa�er Prevention Device <br />Property Owner Rebate Form <br />Please verify the following items: <br />I am the owner of the properly served by the side sewer �vhere the Badavater <br />P evention Device �vas installed. <br />� I worked with my contraclor lo determine the installation location for the Backwater <br />Prevention Device. I understand that the final decision regarding installation location <br />was mine. <br />IX I If the f3ackwaler Prevention Devicc �vas installed on my property: <br />� • I have been shown how to acr,ess, inspect, and maintain my device by my <br />contractor <br />• I understand the City viill not maintain the Backwater Prevention Device. I <br />nm exclusivcly responsible to maintain il and to keep it in good e�orking <br />order. <br />• If I sell my property, I�vi" make the buyer aware of the Backwater <br />Prevention Qevice and the need to mainlain it. <br />Choose one of the following: <br />Lj As of novd, my property has no downspouts or other �;�site drainage that connects to <br />the side sewer upstream of the installed Backwater Prevenlion Device. <br />or <br />I still have downspouts or other onsite drainage that connects to the side se�.ver <br />u� : tream o( the installed Backwater Prevention Device. I u^.�'erstand that leaving these <br />conner,(ions means that ihe risk of ilooding from do�vnspout or onsile drainaye rernains. <br />I accept lhat risk. <br />Signatur _ _� ���' 'Lf '—lL—_—, Date _ ���1 <br />� � ��. <br />F'�r�e 2 of 2 <br />Revised D9109/2014 <br />