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� <br />� <br />Backwater Prevention Device <br />Propert� Owner R�bate F�rm <br />Please verify the following items: <br />[� I am the owner of the prct:�erty served by the side sewer where the Bar.kwater <br />Predenlion Device was instaUed. <br />I �vorked �vith my contractor to determine the installation location for tne Backvdater <br />reveniion Device. I�inderstand that the final decision regarding installation location <br />was mine. <br />�_J If the Backvdater Prevention Device was installed on my property: <br />• I have been shown how to access, inspect, and maintain my device by my <br />contractor � <br />I understand the City ��✓ill not maintain the Backwater Prevention Device <br />am exclusively responsible to maintain it and to kcep il in good working <br />order. <br />If I sell my property, I will make the buyer aware of ihe Backwater <br />Prevention Device and the need to mainlain it. <br />Choose one of the following: <br />❑ As oi no�v, my propeity has no downspnuts or other onsite drainage that connects to <br />the side se����er upstream of the installed Backwater Prevention Device. <br />or / <br />�still have downspouts or other onsite drainage that connects to the side sewer <br />upstream of the instalied Backwater Prevention Device. I understand that leaving lhese <br />connections means that ihe risk o( floodinq from downspoui or onsite drainage remains. <br />I accept Ihat risk <br />Siynature / � _� ����: r Da te _ � — 5�=� � S <br />Page 2 ot 2. <br />Revised 09/0917014 <br />