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' I i <br /> � i <br /> �' Backwater Preverition Device I <br /> ,� Property Owner Rebate Form � <br /> i <br /> Backwater i�revention Device �ebate Form , <br /> � <br /> � � <br /> I'�inf and ieturn lhis form wiUr yow rebate package � � <br /> Property Owner Name: _ �C Q �"��Q__ i___ ` <br /> Property address: 7� �`� � Q[�,- _� . ___ i <br /> � <br /> City: I�""V�fJrt�_ _ _State: Ii�M� __ Zip: __��Z-O I I <br /> I � i <br /> Mailing address (if diKerent): _ _ � ; <br /> —1--- ---- <br /> City: ------- -- Statc: --------zip' -- � <br /> Email, address: �-tt�$�S�l�m(�r.SL.Iu�P�hone: � �,__ ? <br /> � <br /> �G I <br /> Cost to install Backwater Prevent�on Device: 5� SC�,' � <br /> /—__ <br /> Rebate Package Checklist ' <br /> ('le.as� chr�r.k fhaf ynu have r,ompleted ancl included t�e (ollowin,q ifems in your � <br /> submission. llems rndir.ated as(CONTRACTDI2/ will be provided fo you by your � <br /> contracfor. i � <br /> I � <br /> [��hie completed (3ackwafer Prevention De•�ir.r, Re6ale Form (,hi.c /ormJ � <br /> JI- � t <br /> � � h1.1p of �he property wilh loc�itic�n �( insLilled liack�4,�ter Pievenhon Device � <br /> [CON�fRACTOR] i i <br /> I <br /> [] A copy o( Ihe cornplel�d Backwa��r ('reven(ion De�ir,e Final Installation Checklrsf � <br /> [CONTRACTOR] I <br /> �l� 1 he itr.mi�ed mvoic�� shoviin� businrss n:�me, nddles,, license nwnber and detailed ; <br /> cOs�s i�f mstallafinn arn1 m,iteri�ls. (CONTRACTOR]. �ole: No �ebafe wiJl exceed fhe � <br /> r��r�i r.psr o�rn�� insfr�llri6un nl lhr� h:�ck�va/er provenfinir devicr. work. , <br /> � � Vr,ndor Paymcnt Option l-onn signed by bath lhe property owner and r.ontrar.tor IF . <br /> you would likc> the City of Lverett to pay Ihc� ConlractoS difCC.�ly OII1RfWI5C, the: rebalr <br /> chsv k vdill he made out and deliverecl lo you. I i <br /> /�� I i <br /> � 4ompleted and siyr�ed Form W-9 (Request for T�xpayer ldentificalion Number and j <br /> � erhfif:ation) � <br /> � � Page 1 of 2 i <br /> � ! <br /> c <br /> � <br /> Revisni� 09/09/J014 � <br />