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Backwater Prevention Device <br />Prope,rty O�+vner Rebate Form <br />Backwater Preventiora Device Rebate Form <br />Prin( and return this form with your rebate packago <br />Property Owner Name: �N i�-s �S 1'e « L <br />Property address: �1� <br />City: �U�,re� State: �� <br />Mailing address (iF <br />City: <br />State: <br />"Lip: / �'� I <br />� <br />Email address: Je�r�� c551,)`"��s' co�?� p��one: (}� )�`7^ 0// <br />Cost to install Backwater Prevontion Device: $ ays ��� <br />Rebate Package Checklist <br />Pfease check fhat you have completed and inr,luded the following iterns in your <br />submission. Hems indicated as (CONTRACTORj wil! be provided to you by your <br />confractor. <br />�The completed Qackwater Prevention Device Rebate Form (fhis form) <br />j� Map of lhe property wilh location of insialled Back�valer Prevention Device <br />[CONTRACTOR] <br />[l,�A cnpy of the completed Backwaler Prevention Device Final lnstalfation Cher,klist <br />[CONTRACTOR] <br />�The ilemized invoice showing business name, address, license number and detailed <br />costs of installalion and malerials. [CONTRACTOR]. Nole: No rebate will cxcr.ed fhe <br />to��l cost of the installation of the baclnvater prevention device work. <br />j�� Vendor Payment Option Forr» signed by bolh lhe preperty owner and contraclor IF <br />you would like the City of Cverelt to pay the Conlractor directly. Olherwise, the rehate <br />check will be made out and delivered to you. <br />�% �A completed and signed <br />/ Certificalion) <br />Revisrd 09/D9l2014 <br />Form W-9 (Request for 7axpayer ldenlification Number and <br />Page 1 of 2 <br />