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Backwater Prevention Device <br /> d Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Prinf and return Ihi:; lorm with yuur reb��te packaye <br /> Property Owner Nc3fTIC: �\nr�t�, n„"•,r <ti, �t� ,�Ju r <br /> . ��-- <br /> Property address: r���,�(,. (_i_�_, r (�,i� _ <br /> City: `_�,_,,r����-- _5tate: w!�- ZiP; `I��ZC: I � <br /> Mailing address (i( different):_ <br /> City: --- -- -- State: __ ziP� ------- <br /> Email address: C�.r_� 1 � � ti • � CJ�-� _ Phone: (�1.z.� � l,;'1 5�.;��_ <br /> Cost to install Bacl�water Prevention Device: 5 Z��jCSv �W <br /> Rebate Package Checklist <br /> f'lease r,heck Ihat yc�u h<,ve compl�led and included the fo!lo�vrng items in your <br /> submission. Ilems iiidica(ed as(CONTRACTORJ wiN he provided lo you by your <br /> confrac,tnr. i <br /> � The completed H.�ckwalerPiPvenlr�m Devic,e Rebate Form (Ihis (onn) <br /> � -_ Ntap of the propeiiy �vith location ��t installed Back�vater Preven6on Uevice <br /> [CONT.RACTOR] , <br /> � A copy o( lhe con�ipleleri ti��ckw.i�er ('irvr,n6on DrvrcF� l inal Installahon Ch��ck6sf <br /> [CONTRACTOR] <br /> [� �liF� itemized invcir.e sho�ving busines; n,ime, ad�lress, license number and det�jded <br /> ccs�s of installation and m��teii;�ls. [CONTRACTOR] Note: N:� �ebafe will exceed!he <br /> +��tal cost ol(he installatinn nf�he bac,!<wa�er prevention device work. <br /> �Vendur('�yment Option F�urn signrd by both the property otvner and contrar.tor IF <br /> you �vould lihe the City o( 1=vorell to p.jy ihe Crmhactor directly. Othenvise, lhe re�baf�� <br /> che k wdl b� made out and delivered to you <br /> ( completed and 's;iyned 1=orm VV-9 (R��yuest for Taxpayer ldentiFication Number anci <br /> ,erti ation) <br /> I'�ye 1 0l'l. <br /> Rov�sed 09�09;2n14 <br />