Purcellville, VA · Loudoun County
Basement Backflow Statement
This statement documents an owner’s or builder’s understanding of sewer-backup requirements for new construction, finished basements, or renovations submitted for town permits.
What this form is
For new construction, a builder, contractor, or owner completes one of the statements and provides it with the application for a Certificate of Occupancy. For a finished basement or renovation, the property owner completes the applicable statement and submits it with the zoning permit application. The statements address sewer-backup requirements and responsibility for losses or damages caused by sewer backflow.
Who needs it
Builders, contractors, or owners seeking occupancy for new construction, and property owners applying for a permit to finish a basement or renovate.
How to submit it
For a finished basement or renovation, include the completed form with the zoning permit application. For new construction, provide a completed statement as part of the Certificate of Occupancy application.
About notarization
This document is signed without a notary; the signer signs and dates the applicable statement.
How to submit this form
- 1
Download The Statement
Download the Basement Backflow Statement.
- 2
Complete The Applicable Statement
Complete the statement for new construction or the applicable owner statement for a finished basement or renovation.
- 3
Sign And Date
Sign and date the applicable statement.
- 4
Submit With Your Application
Provide it with the Certificate of Occupancy application for new construction, or include it with the zoning permit application for a finished basement or renovation.
Frequently asked questions
- Who completes the Basement Backflow Statement?
- A builder, contractor, or owner completes a statement for new construction. For a finished basement or renovation, the property owner completes the applicable statement.
- How do I submit the Basement Backflow Statement?
- For a finished basement or renovation, include it with the zoning permit application. For new construction, provide a completed statement as part of the Certificate of Occupancy application.
- Do I need a notary for the Basement Backflow Statement?
- No. This document is signed without a notary; the signer signs and dates the applicable statement.
Need something notarized?
This Basement Backflow Statement doesn’t need a notary — but if you have another Purcellville form that does, a commissioned online notary can help.