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1 , <br /> �. Backwater Prevention Device <br /> �� � Property Owner Rebate Form <br /> � <br /> � <br /> Back:water Prevention Device Rebate Form <br /> Prinf:and retum this form with yourrebate package <br /> Properly,Owner Name: _ _ �r,,�n { ���v��¢. ��q,,, <br /> u ' <br /> Propeity address: t�� Uv�.v� AV� <br /> 'City:'_ �I�Cva� State: �/`fF�' Zip? q`a�� <br /> Maili�g�idilress (if different): <br /> ���ty' -- ' State: :`Zip; <br /> •Email address: '�`^e.ws-���,C� phone: ( �`O ) �1�t-b".�l <br /> Cost;to install Backwater Prevention Device: $ `Z�Cj f1U � (S� <br /> i <br /> Rebate Package Checklist <br /> Please cl�eck that you have completed and included the (ollowing items in your <br /> submission.,Items indicated as(CONTRACTOR) wil!be provided to you 6y your <br /> contr'actor. <br /> ❑ The completed Backvra(er Prevention Device Rebate Form (this form) <br /> ❑ M�p of ttie property �vith location of installed Backwater Prevention Device <br /> [CON'�RACTORJ <br /> ❑ A�copy of the completed f3ackwater Prevention Device Final Installation Checklisf <br /> [CON�fR/1CTOR] <br /> I <br /> ❑ Tlie itemized invoice showing husiness narne, address, license number and detailed <br /> costs'oi installation and materials. [CONTRACTOR�. Nofe: No rebale will exceed tho <br /> tvta!rost o! the installntion of the backwafer prevention device woik. <br /> ❑ A iVenda;Payment Optron Form signed by both the property owner and contractor IF <br /> you w�uld like the Cily of Evcrett to pay lhe Contractor directly. Olherwise, the rebate <br /> check will be made out and delivered to you. <br /> I <br /> ❑ A.completed and signed Form W-9 (Renuest for Taxpayer ldentification Number and <br /> Certifcation) <br /> � � <br /> , Page 1 of 2 <br /> � <br /> Revised�0910912014 <br /> � <br />