Laserfiche WebLink
gs Ur�ro <br />(DDIVI) <br />CITY OF SOUTH BEND <br />DOWNSPOUT DISCONNECT PROGRAM <br />HOLD HARMLESS AND INDEMNIFICATION AGREEMENT <br />Some older homes have downspouts that drain rainwater from gutters into the ground, which <br />are connected to combined sewers. On heavy rain days, these combined sewers cause overflows, <br />called CSOs. To help protect the environment and local waterways, the City of South Bend <br />offers a free annual program to disconnect those downspouts, cap the drainway, and add an <br />extension to the downspout so the water drains into your yard instead of the combined sewer. <br />Please fill out this Hold Harmless and Indemnification Agreement to receive your free <br />downspout disconnection. <br />1. I, the undersigned, am owner of the property described below. <br />2. I understand that my downspouts are being disconnected in accordance with Municipal <br />Code of the City of South Bend, Ordinance No. 5253-70, Chapter 17, Article 1, Section <br />17-4. <br />3. By signing this waiver, I authorize the disconnection of my downspout(s) by City of <br />South Bend employee or a contractor designated by the City to complete the work on their <br />behalf. <br />4. I understand that City of South Bend employees cannot be held liable for any and all <br />damages resulting from the disconnection of downspouts. <br />5. Once a downspout is disconnected, it will be my responsibility to ensure that the <br />replacement facility, which will be my personal property, is not removed and remains <br />properly maintained and operated. <br />6. I, the undersigned, hereby indemnify and hold harmless the City of South Bend for any <br />and all damages resulting from the City's disconnection of downspouts. <br />Date: <br />Homeowner Signature: <br />Printed Name: <br />Address: <br />RETURN FORM TO: <br />Department of Engineering <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 <br />Fax: (574) 235-9171 <br />Email: hparkhil@southbendin.gov <br />City: <br />Telephone: <br />State: Zip: <br />Quantity <br />Size <br />❑ 2x3 <br />❑ 4x6 <br />Color <br />❑ White <br />❑ Brown <br />Will you be present <br />during the disconnect? <br />❑ Yes <br />❑ No <br />