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VILLAGE OF MAYFIELD <br />DRAINAGE ASSISTANCE PROGRAM <br />DRAINAGE ASSISTANCE REQUEST <br />To assist the Village of Mayfield in evaluating: your request for drainage assistance, <br />please answer the following questions: . 1. Briefly describe the nature of the problem or concern (attach photos if available): <br />2. This Program requires that the Village of Mayfield and/or its authorized agents be <br />given permission to enter upon your property and any other affected properties for the <br />purpose of inspection and/or repair. <br />Are you willing to grant such permission? Yes ? No ? <br /> <br />3. Does this problem affect more than one property owner? Yes ? No ? <br />List address(es) of other affected properties and obtain signature(s) authorizing entry. <br />Address of Affected Property <br />Address of Affected Property <br />(Owner's Signature/Printed Name) <br />(Owner's Signature/Printed Name) <br />Address of Affected Property (Owner's Signature/Printed Name) <br />(List additional properties on back) <br />4. Residents are required to pay 10% of the cost of any repair. If you qualify for the <br />State of Ohio's Homestead Exemption, you may be entitled to financial assistance. <br />? I qualify for the Homestead Exemption <br />Please provide the following information: <br />Name: <br />Address: <br />? I do not qualify for the Homestead Exemption. <br />Telephone: <br />Owner's Signature Authorizing Entry: <br />Requests are filled in the order in which fhey are received; Village infrastructure fakes <br />prec.edence over this Program. If you wish to have your project completed sooner than . <br />the Village is ab/e, you may need to hire a privafe contractor. <br />Please return this form within thirty (30) days to: Village of Mayfield Building Dept: <br />784 SOM Center Road <br />Mayfield Village, OH 44143