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. i <br /> � Backwater Prevention Device <br /> � ; Property Owner Rebate Form <br /> , <br /> Backwater Prevention Device Rebate Form <br /> Prirrt and refum this form ivith your rebate packag <br /> Property Owner Name: �LL��� �LI`�}JL,7'tjJ <br /> � <br /> Property address: __Ll)Z,� C���G�� <br /> City: `C�J �Z�-� State: �V �-1 ZiP; -\ �.� � <br /> � <br /> Mailing address (if diFferent):___�_ (�Z � G (� <br /> City: ��v lS, State: _� �_ Zip: � Z � <br /> � � <br /> Email address, l�ti, _ .�c �(Phone: ( Z\ �,��Z 7 <br /> Cost to install Backwater Prevention Device: b�d� '� <br /> I <br /> Rebate PackagelChecklist <br /> Please cher.k that you have cornpleted and induded the follo�ving items rn your <br /> submission. Items iniiicated as(CONTRACTOR) �vill he provided to you by your <br /> contractor. <br /> Q� completed L3ackwater Prevention Device Rebate Fomt (lhis lorm) <br /> Map of lhe property �vith loration of installed f3ackwater Prevention Devicc <br /> [CONTJ�ACTOR] <br /> �e].� opy of the completed QackwaterPrevenlion Device Final Installafion Checklisf <br /> [CONTRACTOR] <br /> ��fhe itemized invoice sho�ving business name, addre:s, licens.. numher and detailed <br /> cosls of installation and materials. [CONTRACTOR]. Note� No rebate will exceed the <br /> tota!cost o(the instalfation o(fhe backwater prevention devir.e work. <br /> � Vendur Paymeiit Oplron Fonn signed by both lhe property otvner and contraclor IF <br /> you H�ould like the Cily of [verett to pay the Contraclor directly. Otherwise, the rebate <br /> check will be made oul and delivered lu you. <br /> completed and signed Form �N-9 (Request for Taxpayer ldentification Number and <br /> erti i ation) , <br /> Page 1 of 2 <br /> Revised 09/09/2014 <br />