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Backwater Prevention Device <br /> . ��� Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> llllf' 'ji"� �'C�il�l7 !"�n �!'!I� �:4�f1 v)I/I , !�liil!' �'f1�:N:3�u <br /> Prnperty Owner Namc: - -r}�hr. l__Q�v-�_ <br /> Propertyaddress: ;� ',I '� c�c�i� � `:,� <br /> City: (�yr � ,.i�- - _ Statc: _1,.���- -- Li 1,C�;� 1 <br /> - _ _ �' --- <br /> Mailing address .�f dd(crenti:__—_--_----- <br /> City: --- - --- ---- ---- State: --- -- Z� <br /> _ p' -- .. <br /> [rnail address: i'�.�z�•� . "'�,�.n.� �� :{.I, �,�.Phone• •+t 5 <br /> __1 - -- -��--- - ( _._�. ._i.4J Ild`i--- <br /> Cost to install Backwater Prr.vention Oevice: S_ F'.5�=�� �.�''' __ _ _ _ ^ <br /> Rebate Pacicage Checklist <br /> r'Ir�ase check '7�a! you ha��r� �.r. nr�lefed :+nJ;n; liided thr, loUo,�u�y �lern; -n your � <br /> ���h,rr;�.ssu�n I�i,rnti irn1�,:,�;r;1 ,�s(CON�RACI�OR/ �vdl br�prnviderl7o yo�i by your � <br /> ��r,'ract^r <br /> ��a cornplc4nrl R�lckr;afc; 1'ruvo:;tnm l�rv�rc R��Lnle Fumi (th�s lonn) , <br /> '�1.�{�� u( lh��� F�r����t�rty ��,�i'h loc�tion of instrilled Backw:der Pi��venhrm ��;wce <br /> �CONTRACTOR� <br /> i��.���v ul !Iw ��un��:l��l��d ti,��kn;�L�i l hv��.cn'rn�i lluvu��� I m,i� In.s!�ilb�fi��m ('!�acklr:;t � <br /> �CONTRl1CTQR] <br /> l ihc il��nu�nd invoi�:e sli��:�uiy liusinus; nnnic, ,a�t�hu�s�s lir�n�e ninnl'�ci nnd de;��ilnd � <br /> �nsh, ��I �:ns!,�Il;itum and m,�,cri�ds �CGN7RACTOft). lduh:� Nn rnb��te Will cxccedthe , <br /> 'otdl cosl u/If1e rn.tifalla6nn ril thp buchu�+tr�r ����r��,�nrition �let�ic�; �•:ork- <br /> I- ;' I� Vendor Paymerd Ophor; Form signed by h�th the pinpr:ily o��ncr anrl r,onlrar,tor IF <br /> �r�u wou;d hkr, lhc City of Lvurc!t to p;iy th�-: Coiihar,trn rlu��ctly (�Ihenvisn, th� rehtitn <br /> �.hec' t�ill be madn oU; ��id de!�vera�ci �n you <br /> ' A r,ompleted and s�qned Fomi 1�1��9 (flequest for Taxpayer ldentificn�ion Number rand <br /> Cert4�c�tiOn) <br /> P�u1� 1 n' , ' <br /> R�,�,��..n r����n!�r;•�i�.: <br />