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Part A <br />Application No. <br />Name: <br />Address: <br />Date Completed: <br />No. of Downspouts <br />Disconnected <br />Downspout Disconnect Program. <br />Completion Form (DD2V1) <br />Completed by: <br />No. of Downspouts <br />NOT Disconnect - <br />FRONT OF HOUSE <br />riease marx the locations of all disconnections with an X and a Circle at locations where downspouts were NOT <br />disconnected. If all downspouts were not disconnected please fill in part B of this form. <br />Part B I have attempted to disconnect all downspouts at this property. However a disconnection at the <br />locations marked with a Circle was not feasible for reasons here specified: <br />Impervious surfaces Safety risk <br />Other(snecifv) <br />Completed by: (name) <br />Countersigned by property owner: <br />Environmental (e.g. protected area) <br />Signature: <br />By countersigning, the property owner is applying for an exemption from the requirement to <br />disconnect the individual downspout(s) as circled above. If the property owner is not present <br />during the disconnect, the City will follow up to obtain a signature. <br />