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/ . - . . - - . <br /> I Bacl�water Prevention Device <br /> Prop�erty Owner Rebate Form <br /> Backwater Preveintion Dev�ce Rebate Form <br /> Print and retum this form witb your rebate package <br /> Property Owner Name: C_twE.N O�L�I�d �1 L My1 A►J <br /> Propertyaddress: `�-0 ; Cv�y �1rV�. <br /> City: ��-+�� State� w14- Zip: �U� <br /> Mailing address (if different):_, <br /> City: State: Zip: <br /> Email address: Phone: (�Zr7 ) 2CJ� 'y�a�� <br /> Cost to install Backwater Pre;vention Device: $ 2, '�j�.(S2� <br /> Rebate Package Checkli�t <br /> Please check that you have coi:npleted and included the following items in your <br /> sub�;,;ssion. Items indicated as��CONTRACTOR]will be provided to you by you� <br /> contractor. <br /> �� completed Backwater�revention Device Rebate Fonn (this form) <br /> Mlap of the property with locetion of installed Backwater Prevention Device <br /> [CONTRACTORJ <br /> �opy of the completed Backwater Preventiai Device Final Installalion Checklist <br /> [CONTRACTOR] � <br /> he itemized invoice showir�g business name, address, license number and detailed <br /> costs of installation and materials. [CONTRACTOR]. Note:No rebate wil!exceed the <br /> totzl cost of the ins�allation of tlie backwater prevention device work. <br /> �Vendor Payment Optron Form signed by both the property owner and contractor IF _ <br /> you would like the City of Evere,tt to pay the Contractor directly. Otherwise, the rebate <br /> check ill be made out and deli'vered to you. <br /> A completed and signed Forrri W-9 (Request For Taxpayer ldentification Number and <br /> Certification) <br /> Page 1 of 2 I <br /> Revised 09109/2014 <br />