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' Backwater Prevention [;evice <br /> � <br /> �' Pr�perty Owner Reb�te Form <br /> Backwater iPrevention Device Rebate Form <br /> r'rinf �nd retum this f��rm wiU� your rebate package <br /> Property Ownar Name: ' vl�� �� 'ti'�— <br /> Property address; ._t�p�c( ����F3rlRS7 � �/t, � <br /> City� �dL��i.—i T �- <br /> i State: l.�Fl Zip: Q��-,-�( <br /> Mailing address (if different): <br /> City:.-- _— — State: Zip: <br /> Email address: Plione: ( �-5 ) L12 —io�EZ. _ <br /> i <br /> Costito install Backwat�r Prevention Device: � vo <br /> � ,_�, 5ov . <br /> Rebate Package ChecK;ist <br /> Please check tha! you have completed a�7d i,��l�•ded the fo0owing items in your <br /> subrnission. Items indicared as(CONTRACTORJ �-�il!be provided to you by your <br /> r.ontra t;�r. <br /> lhe,com leted Backwa,�r'P��vention nev�:.e <br /> P ` Rebate Form (this torm) <br /> [ (vl.ip oF the property with location of installed Backwater Prevention Device <br /> [�•ONT�tACTOR] <br /> ra�A�PY of U�e completec! l3ackwater Preventiort Device Final lrtstallatiori Checklisf <br /> [CONlRACTOk] <br /> i`�I I lie itemized invoice showmy business name, address, license numher and detailed <br /> c.osts of installatiori aiin materials. [CONTRACTOR]. Note: No rebale will exceed the <br /> total cost r,l the instal/ation ol the �ackwater prevention device work. <br /> �VendorPayment Option Form signed by both the,properly owner and contractor IF <br /> you wo}�Id like the City of �verelt to pay ihe Contractor directly. Otheiwise, ihe rebate <br /> ch �Kwill be made out .3nd clelivered to you. <br /> Fl completed ar,d siyned Forr i W-9 (Request for Taxpaye� Identification Number and <br /> :e�?{+cation) <br /> � <br /> Page 1 of 2 <br /> Revis2d,D9109/2014 <br />