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4E,,. BaGkwater Prevention Device <br />Property Owner Rebate Form <br />Please verify the following items: <br />�I am the owner of the property served by lhe side sewer where the Back�vate� <br />�revention Device �vas installed. <br />,�I worked with my contractor to determine lhe installatiun localion for the Backv+aler <br />Prevention Device. I understand that 1he (inal decision regarding installatior. location <br />vfas mine. <br />If the Backwater Prevention Device was installed on my property: <br />. I have been sho��n how to access, inspect, and maintain my device by my <br />conlractoi <br />• I understand the City will not maintain the Backwater Prevention Uevice. I <br />am exclusively responsible to maintain it and b keep it in good working <br />order. <br />. If I sell my property, I will make the buyer aware of the Back�valer <br />Prevenlion Device and the need to maintain it. <br />Choose one of the following: <br />of now, my property has no do�vnspouts or other onsite drainage fhat connecls to <br />� he side sewer upstream of the installed Backwater Prevention Device. <br />or <br />O I still have dovrnspouts or other onsite drainage that connects to the side sewer <br />upsiream �( the installed Backwater Prevention Device I undersland lhal leaving these <br />connections means that the risk of flooding from downspout cr onsite drainage remains. I <br />accept that nsk. <br />-' l <br />;_ <br />� =' <=j��� ' ���(�;-��e�. '� � 2� jJ' <br />Signature Date <br />Page2o'2 <br />Ftevised 0 910 912 01 4 <br />