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splrit4. <br /> k: <br /> Aw Yi <br /> CITY OF SOUTH BEND <br /> DOWNSPOUT DISCONNECT PROGRAM =` _ T ?` <br /> HOLD HARMLESS AND INDEMNIFICATION AGREEMENT es6s <br /> A note to the resident: <br /> We must ask that you sign this waiver as a formality required by the City of South <br /> Bend's Legal Department. Please be assured, however, that you can expect high quality <br /> materials and workmanship. The intention of the Downspout Disconnection Program is to <br /> provide a free community service to homeowners. <br /> I, , hereby indemnify and hold harmless the City of <br /> South Bend for any and all damages resulting from the City's disconnection of downspouts. I <br /> understand that my home is in violation of the Municipal Code of the City of South Bend, <br /> Ordinance No. 5253-70, Chapter 17, Article 1, Section 17-4. I, the undersigned, am owner of the <br /> property in violation of the aforementioned ordinance. By signing this waiver, I authorize the <br /> disconnection of my downspout(s) by City of South Bend employees. I understand that City of <br /> South Bend employees cannot be held liable for any and all damages resulting from the <br /> disconnection of downspouts. Once a downspout is disconnected, it will be my responsibility to <br /> ensure that the replacement facility, which will be my personal property, is not removed and <br /> remains properly maintained and operated. <br /> Date: <br /> Homeowner Signature: <br /> Printed <br /> Name: Telephone: <br /> Address: City: State: Zip: <br /> RETURN FORM TO: Quantity Size Color <br /> Department of Engineering <br /> 1316 County-City Building 2x3 White <br /> 227 West Jefferson Boulevard <br /> South Bend,IN 46601 <br /> Phone: (574)235-9251 <br /> Fax: (574)235-9171 4x6 Brown <br /> E-Mail: ajacob@ci.south-bend.in.us <br />