2222 BAKER AVE 2022-04-12 - Laserfiche WebLink

�" Backwal:er Prevention Device ' �� Prop�rty Owner Rebate Form Backwater Prevention Device Rebate Form �'��n, i�tl ��'r, �i fh,�; 1�;��;� .�;t;; ,:,�;riah.r„ ��u.i��y.. � Proparty Owne� Name: _ �le �,�.,-L.0 -- -�Ql ' �/ -- -- - - - - - - �- Pruperty addn:ss: _ _�r�� - - -11'-��_ _ �v `- -- — --- c�iy: _c'��!�.� �77 --- - s�a��: _ �</« -- Z'P: —_l�_Z_ °G _ Mailing address �d dif(r:r�rlk � , -_--- -- --- -- ----- --- ----- City: - - - - —______ - - State: --- -- Z�N' -- - — -- Finail address: . ---- - - -- -- Phone: ( �lli -) �5�=�1�_� Cost to install Backwater Prevention Device: 5 .�-� �C� • `'U Rebate Package Checklist l"l• 1;:'_' r'II('r:k I!!df :�.�. 1 �I.il " ..i.l7if;lt�In�/ fll`,l !�1C1'�!/�'(f 1/]G' �q/IOWIII� IlC'/I75111 }�U!/I s-,hrri,.ti�:�,,�i ih•;n, :�;;f ;�;r�l ��r. �CON�RACTORf t:�ril be provid¢d to ynu h}�}�our rur�lr ��rfnr. I � I fiF �-nm��kr'��il (ir;ckn�n!rrr ('inv��ntin�� L'�;tvr.c Iti'cb��to Fonn (7lrrs lonn) 1��1,1 y� ��i tln� �nn:��.it,, ,.;i'h I�,c;�lion o( mslallud Hackwa�er Pi��vrnti�m [)evlcc [CONiRACTOR] i�..'/'� , i��ly U� �Il�� i.;llll��.��t`�! �i�. G��.. .. 4 ��! �.��'1�. 'I i_)� _��'i1 / If; 1� �'L�.JI�J('i�:l !�!I -iii`;.,, �CO�JTRACTOR) j��fll' I(C'lll;�'(j I'1��),i r, '.�iul7�^��) I�U:,Illl'�.`I II:1fP��, :I��iil!'.J . �I�:�.`IL'li� f111111�iC1 ;111�� (:CI�71��'�� r,.,��,L; n( nsl„Il�ttinn �u��l rr,i'��n.�l�� [CONTI2AC1�ORj l;'r,t�� Nn i�rb,�t�� i��rll ��n��ur�ill4�� In;:�l r.ns.t ul fh�� rn.viull,�fiuri ril iite f�,ic!<<v��f�'� (nevc�Vi��n di'i-r�:�r tvurl< �•�� L�endni I',iymnnt C)��trnn l ,vn� si��ned hy br!li llur �noperty obvnrr and cuntr�ctn� li= vnu �:�uuld I�k�� ih�� C;ty nf I.verr�tt tu pay the Cnntradni rLrectly. Othuitivise. thc re�atc r.�i�r.k,�:�i:l be imu1�� ul anil del��verud to yo,i. �`-' !� ��.�mir:lr�t�d and r,ignr�r. I'nrn•� N.' '? (R��i.c;: for �axnuy�:r I;Irnl�lnr;lion Numbei and C�:•l��n ,�hnr1 i`,iqe 1 of Z .� . �J . . �'+ ... � .