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; <br /> Backwater Prevention Device <br /> � Property Owner Rebate Form <br /> E3ackv+rater Prevention Device Rebate Form <br /> Print and return this form �vith your rebate packagc � <br /> Property Owner Name:���ci�_. ����f�,Uf� _ <br /> Property address: /S L! �����r�� � G,� ��V`�. <br /> City: �z/�i�� __._ State: (� Zip: ��a/ <br /> Mailing address (�f different): /v/� _ <br /> City: _ __ State: Zip: � <br /> E;nail address:�'Ft�itJ d�v, U�„•�:'i. Phone: {1i��-- ) �5���l`�� <br /> n.1� „ , <br /> Cost to install Backwater Prevention Devica S Z+S�� ' �� <br /> Rebate Package Checklist � <br /> Please rheck C at you have completed and incl��ded the follo�a�ing ifems in your <br /> suLmission. ltems rndicated as�CON7RACTOR] will tie provided to you 6y your <br /> cn itractor. <br /> [�"1�he completed Backv��aterPrevention Device Rebate Form (this (orm) <br /> [__Ji Map o`the property with Iecation of installed Backwater Prevenliun Device <br /> [CONTRACTOR] <br /> j71 A copy ot the completed 5ackwater Prevention Device Final Instaflation Chec!<Iisf <br /> [CONTRACTOR] <br /> � he itemized invoice shov��ing business name, address, license nurnber and detailed <br /> costs o( installalion and materials. (CONTRACTOR]. Note: IJo rebate will exceed the <br /> tofnl r,osf of!he installation o/Ihe back�vater prevr.ntion device tvorlc. � <br /> �Vendor Payment Optron l=nrm signed by both the property owner and contractor IF � <br /> you woultl like the City of L'verett to pay the Conlracior directly. Othervvise, the rebate � <br /> check vill r,:� made out and tleliveretl to you. <br /> � - A completed and signed f-orm 1N-9 (Request for Taxpayer ldentificalion Number and <br /> Certi(icalion) � <br /> Page 1 af 2 <br /> � <br /> Re�'ised 0,9,h79l2014 <br />