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G•,� BacF;water Pr�vention Device <br /> ���r� Prop�erty C�wn�r Rebate Form � <br /> Bacicwater Prevention Device Rebate Form � <br /> � �7� ,�'lili ,'�l':� i� 1.1 �'�'�, ll�n, iL it'Jdi^' ':H�:IllP]P <br /> . - i <br /> !'roperty O�vncr Name: __ �<iC�,'�_��� .u(� -------�-- <br /> Property address: 7/� ? ,`' <br /> L�___1F��P� - 1T• -- --- <br /> City: ___ _�=_v�/,�,�1'1 --- State: �4J � • _ Zip: �� �S':t� _ <br /> �Jlailing address ,�f diflcrer�'Y.___ __ ___ <br /> City: ---------- State: -- -- --- Zip - -- -- <br /> Email address: Phone: -/�-`� ;L� �gt�j <br /> --- -- ( —�—�-- <br /> Cost to Install Backwater Prevention Device� 5 2 � SU� . �1 L� � <br /> Rebate Pacl<age Checkli:.t <br /> '��.9SC ChCC�•. �!'d!}'O�! �Id�.�P (',!71�:(Hi?i! :Uit);lli;lil:�t�:l i71t' l(iilU'.YIIIU IiBRIS Ill �GUI ' <br /> .�,!�nv�c;��r� i!nnts md�r�ird as�CONTRACTOR.j will h.: provrdod to you by you, <br /> nn!rectc,� � <br /> `L.i(li�� � uriululud t3acktvn�r�r Fruvenhon Ur,wcc f2ehtNc Forirt (this (onn) <br /> � <br /> �� ��E �.' t���� uiopeiiy v.�th lui�.�a;iur o1 irs;a 1a�113a��kwata !'iever,t�on D��vlr,a <br /> �CON 'RACTCR] <br /> ��;q,�� �>f th�� ,��vnn�r�h��l H:�rt,,:-,itr�r l';ri�entinn Device Finallnst�llafr��n Checlilisf � <br /> �CONTRACTORJ <br /> ✓ I i �� �t��n�i.� ,�: u ��u. r >I�,:,: �i � I,�ir,inus:, i�u'nN, ,:�1� � . ;, hcCnSe 'lUinbe� and dClt7detl � <br /> � �_��ts nl irti!,�I �;;��,n ;�nd ri,it��r �ds �CONTI�ACTOf2J '•; No rehr�t�� tv�N exca��d th�� <br /> ��;f,�i cus! ul fNr� n�sfallnh�m nl fh�: b;,cr,:•,:,,fe� �,�uwr;�,. �i Jevrce wwk � <br /> irA Vcrrdor Paymenl Opfinrr I?orm siy�ied by bolh the property owner and con'rar.for 11=. <br /> ,n i 4v��ulri IikP the C��y uf Ever�tl �o nay the Conlra��o�directly. Othentiise, thc rebat�� <br /> �1u� k �•;ill he m;+rle rwt and de'ivered to you. <br /> ' i� complu�c�1 a�-�d ro�3nc� For.^ N!-9 (Request �or Taxpoyar ld�;;dificaliun Nun�bcr and <br /> Ceridic3'.in�i) <br /> �'aa� 1 0�2 <br /> 'rii':s�:il �...��r�;.�'','��14 � <br />