|
-' Barkwater Prevention Device
<br /> �
<br /> 4��TT Pruperty Owner Rebate Form �
<br /> E3ackwater Prevention Device Rebate Form
<br /> P• ��. �i- ,; ��..�. �, .� f. , r. 'n y.,u� n„� �F� r��� :c �
<br /> �
<br /> Property Owner Name: i— '�� /_�`=� ` -�? --.- . — — '
<br /> _�--
<br /> Property adr+:�ss: �1 __.�_i __iS�.a isy _ - - - --
<br /> City' -_-l� : •-'���T -- -- State: _(�/,-, ---- Zip: v `� �='i .
<br /> Mailing address i�! �;if`erenlj:_ �-�1e`� i��` --�� —�_`-`--- --
<br /> •_— - -
<br /> � , _ ..
<br /> City: '_-�:_���r ` �-- State:(,G•..� — zip �--f'�a � L
<br /> _ �
<br /> t=ir�ail address: -- - --- - -- Phone: ( `�7� ) ��/Ei F���A
<br /> — — � � ^i ) �t ---
<br /> Gnst to mstall Bar.kwatcr Prevention Devir.e 5 ,a .� ` �
<br /> R.ebate Packaye Checl;list
<br /> ��d`�I�i' �:�)1'�'k (��,1! �'Uil �4)�,:�i �'.�I;tl��C'(':� ;7!1�: �! .. ,��i��� J4' If)�i')t:�lll:� ;!r�fl�tilJl j�1i1/I ;
<br /> �,hrr,,�s�_��n I!r�rn�: a�cL�;:te:l ,�s fCOMRACTOR/ �,•,.h t�c ��rowded fn you hy ynur
<br /> ,.r.;�•,..lrrcr
<br /> � � �„� � , . pl��t��r�1 lirir.k�:�;itcr I' ,,�,,,��t-��•� (r„�, ., l+�v��ifa Fom� (fh�s loirnj
<br /> /
<br /> �� ):1 i;� ��f �li�� �� ;�,�rr!y wi�li Inco�hnn �r` installoill�,ir.kwrater Prnvenlion D��vice
<br /> [CONTRACTORj
<br /> �
<br /> I(_�� � ���:�- nt Vir� � ��n��n r'rd R;u,�itc��itri 1'rr,i-r�;lum 1_�uvrr.r. 1 in,�l Irs!rill,�tiun Clleckl!tit
<br /> ((:ON112l�CTOk)
<br /> � �� I ��„ Ih•I:i'.V•�l Pilri� ., �,�1(lb1'lllr� hll'1J`��f'J', f'.:Illl�_'. .l'1rifL",;,, �ICCI��.q f'U�llf)Cf fllll� (���t:l.�('�� -
<br /> � ���.1, r_4 i'�ot.:Ilaiiun urnl m�i;en.�15 �CUNiRACTORj Notc. lJ�r r�:h,ih� �v�Rrxi:cc�l �Nr �
<br /> lr�f,i! ����.�f ot th� rn5t.:�N,�tion o/fhc� bucA�t.+tcr ��revenhnr� devi�:� bt�or'6_
<br /> �� ' 11 Vr.ndor 1'ayment O��tron Form �i�aned by hr�!h U�e pr�prxty o�yni�r ;�nd coniractar IF
<br /> �,rni H�ould liki: ihc City of !`verr�it to p,:y tl���� C�mhrar.lor dircrclly Olh�rnvise, lhe rel�atr.
<br /> �incr,k v:ill !�e made uut .in�i �ie'ivrx�td to y��u.
<br /> i"� 1� r,�mq�let�ni ,�rni ��.,yn��r1 I n�rn VJ-S� (Rn��u�st `rr T;�x��n��rr Irlc nh!ic�hun Nun�ber and
<br /> t_:�:iid��:,il�t�i•�) � �
<br /> f��+J�� 1 .-f 2
<br /> ' ,, , � ; ,. i � ��.t
<br />
|