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Information <br />Dwelling Type <br />❑ Residential <br />Total number of external downspouts: <br />Total number of internal <br />❑ Commercial <br />downspouts (i.e. not visible from <br />❑ Industrial <br />Number disconnected from city sewer: <br />outside of property): <br />❑ Institutional <br />Number connected to city sewer: <br />Indicate if your building <br />❑ Has an internal only roof drainage system: <br />❑ Is a registered historic structure: <br />❑ The property is within or adjacent to a wetland or wellheads? <br />Supporting Documentation <br />Checklist of items you must submit in order to make a valid exemption application: <br />❑ Completed and signed Mandatory Downspout Disconnection Exemption Application (this form). <br />❑ Additional information that would assist us in the review of your application, such as photographs. <br />Please ensure that the photographs identify downspouts and surrounding areas. <br />2 <br />