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Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />i <br />Print�artd relum this fonn with your rehate package <br />Property Owner Name� � i. 0 <br />Property address: � (7- �� �/� a„ <br />i i �,r. <br />:c��v:', , ✓ P ��� �'1�� . z��: �1c� Z� <br />•:State: <br />MailiPg address (if.different): <br />City: _ <br />' State: <br />Email address: O h � \,,, (��� Cp�^ <br />�-�_� Phone: <br />Cost to install Backwater Preven ion Device: $ Z�U � <br />Zip; �_ <br />c� �- dy� <br />Rebate Pa�ckage Checklist <br />Ple��se check that you have completed and included the (olfowing items in your <br />submission. ltems indicated as (CONTRACTOR] will be provided to you by yvur <br />contr ctor. <br />��J The compieled Backwate� l�revenlron Device Rebafe Form (fhis form <br />) <br />[� Map of the property with Inr,ation of installed [3ackwater Prevention Device <br />[CONTRACTOR) <br />�'1 � �oFY �f thr, completed Backwater Yrevention Devir.r. Final Installation Cher.klist <br />[CONTRACTOR] <br />!!� ThH item¢ed invoicn :;hovnny business name, address, license numhr.r and delailed <br />�:u�:ls nf inslaliation and mntcrials. f��NTRACTOR]. lJolc: lJa �ebn(e wil! excer.dlhe <br />h,�nl r sf of thr, installation of Ilte b:�ckvraler prevenlion device work. <br />A Vendor Payment Opli� a Form si g ne d by bo t h the ro ert <br />Y o�� w o t i l d l i k e t h e (: i t y o f Evere t: to a ���P r P � Y � W n e r a n d r, o n i r a c t o r I F <br />P Y ..oniracl�r directly. Othenvise, the rebate <br />check�ne made out and delivered tu you. <br />Page 1 ot2 <br />�"�'�S�d 09/09I7014 <br />