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. i � <br /> Backwater Prevention D�vice <br /> � i - Property Owner Rebate Forrr� <br /> � <br /> I <br /> Backwa�ter Prevention Device Rebate Form <br /> i <br /> Prrnl and refurn this form ��ith yo;.;r rebate package <br /> Proj�erty Owner Name: �,,�� f. '�p +{er <br /> I <br /> Property atldress: f � �.��v�hn r�i <br /> � ve <br /> City: ��e Y'E �+ _ State: <br /> U//� z�p: 1��0/ <br /> Mailing adilress (if different):_ <br /> C��' SYate: <br /> ' �1 \ _Zip: <br /> Email addr,ess: CT'C^.{�e� (e� �C;�m�,� ��t'Ylphone: ( �2S )•LS2-3993 <br /> � �— <br /> Cost to ins4ali Backwater Prevention Device: $ Z .�t7ti�c517 <br /> , <br /> J <br /> Reb�te P�ckage �hecklist <br /> Please check that you have completed and induded the foUowing items in your <br /> su6mission; Ilems n�dicafed as(CONTRACTORJ wrll be pmvided to you by your <br /> contractor. <br /> ❑ The completed Backv��aler Prevention Device Rebate Form (this (orm) <br /> ❑ Map of the property vdilh lor,ation of installed Backwater Prevention Device <br /> [CONTRAC,T012] <br /> � <br /> ❑ A copy q'f�the completed Bacicwater Prevention Device Final Installa�ron Checklist <br /> [CONTRAGTOli� <br /> [] The iteiTiized invoice showiny business name, address, licen�e number and Jefailetl <br /> costs of installalion and ma,erials. [CONTRACTOR]. Noie: !Jo rebate will exceen`the <br /> lutal cosl of the installaiion of the backwaler prevention device work. <br /> (.� A Vendor�Payment Option Form signed by both the property owner and contraclor IF <br /> you woiild like the City of Everelt to pay the Coniractor diractly. Otherwise, the rehate <br /> :heck w;il be made out and delivered to you. <br /> ❑ A c;impleted and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certification) , <br /> i � <br /> i <br /> . i Page 1 of 2 <br /> Revised 09/Og/Zp�q <br /> I <br /> � <br />