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:I <br /> Backwat�er Prevention Device ; <br /> F� T Property Owner Rebate Form ! <br /> Backwater Prevention Uevice Rebate Form <br /> I'����t rirrl ret��rn lhi.e form �•nfn your rebati� por,kage � <br /> Property Owner Name: ��/�S !�%1 T� n/= ��ll,�c��,_�_Jf�vi'r�-.�1 ' <br /> _ _ I <br /> Property address: _ �y ?o _.L.Z�r-L,.�, _ --- – ! <br /> City: _/_�JG./_'r".�rl-- ----- - State: __QJn_ �. -- Z�F' 1 � �r / � <br /> � <br /> Mailiny address (�f differFmt):_ 5��� S� �i/�_�/l�f'.��____�� <br /> — �— i <br /> acy: 1�,�'��A.,�_r<:..�1---- st,��: ;<��� _____� z�P: _�z � "'> > <br /> Limail address: /�J/Ic��'�;-..i /�(�-J (�fr n .�Phone: (.�z 5' �_���=.�f`/"�� <br /> Cost to install Backwater Prevention Device: 5_ z,����U •_�� U ��__ <br /> Rebate Package Checklist i <br /> f'lr.ase check Ihat you have cornpluted anJ u��:luded Ihe 1olloKinry rtems �n your <br /> submission. Nr,ms indir.nh:d as(CON7RACTORJ .vdl he provided lo you by youi ' <br /> cwrtraclvr. <br /> I hi; r,omplelCCl I3JCkY�ater F'reverttion Ucti�ice Rebufe Forrn (this (ormf ' <br /> (�!�A1��p uf th�; prop�a�ty vrdh location ot ins;alled ISockw.�tei F'iwention D��vice ; <br /> �CONTRACTORj � <br /> � -�?'� co�ry o( the comple�ed B��r.kv�uf��r I're��-��nfir,r� !_)r.��ir.e F=�nnl Insf,�llalion ChockGst � <br /> [CONTI2ACTORJ <br /> � , �h�� deinvn�l ii�,vuia� shn�vinq husinus�; n�+n,�r, �iddi��ss, ficer�sc nurnher and dr.t.iderl I <br /> r,os�s ot inst:dl.diun t�nii rn,3trmals (CUNTRACTORj Nule No relyde wdl r.xcend the � <br /> tuf�l r.ust o(;h�; nrsfallahon o(fhe h�ichw.ritei ��rc;�r_�nLon dt�vrce wo�k. � <br /> �� i A Ve�n�loi I'ayrnent OpGun Fonn si.�ned by bolh thc prnperty owncr and wntraclur IF <br /> yuu wuu�d hke lhe City of Fvnret� l�� pny thr. Contractor dirc+clly Othet�vis0. th�� inbate � <br /> r.hr.r.k wdl bn niade out and �'cliver��td lo ycu � <br /> �_ � completed and signed Fonn W-S (Requesl (o� Taxpnycr ldentilir,ation Number �nd ; <br /> Cer�dic:ition) <br /> Peye 1 0! 2 i <br /> � <br /> i <br /> Kev�sed o9rU92n�4 � <br />