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i <br /> ; <br /> Backwater Prevention Device � <br /> Pro�erty Owr�er Rebate Form <br /> , <br /> Backwater Preventiox� Device Rebate Form <br /> Prini and return lhrs fnrrn, wifh your rebate packagF � <br /> i <br /> , I <br /> Property Owner Name: _��v/.c� S /.�e-_�-�-��,r1- <br /> Property address: �r_'�-�� '��t��.ko_�i?l��c�a� � <br /> _� � <br /> City: �—v�.i c,,{-4- ----- State: �,J^c Zip: `��6 �/ ` <br /> Mailing address (if different):�3��� �J2�-L� �� � <br /> City: ��/���1 l --- State: _-U�Z�P: �� � <br /> Email adiJress: � Phone: (�/J-S ��Z- �j� '7�( ; <br /> , <br /> Cost to install Backwater Prevention Devicc!: 5 'Z �`QU .6� , <br /> Rebate Pacicage Checklist <br /> Pfease check that you have r,ompleted and included the fo!lowing rtems in your <br /> submission. ltems indicalod as(CONTRACTOR] will bc provided lo you by your <br /> contractor. <br /> � The complet�d Aackwaler Prevention Device Rebate Form (this,(orrn) � <br /> (�Map of ihe property w�th location of installed Back�vater Prevention Devlr,e � <br /> (COfJTRACTORj ' <br /> �.�� co{�y of ihe completed F3ackwater Prevention Dovice Finaf InstaNation Checklist <br /> [CONTRACTOR] <br /> i <br /> �,}�i he iternized invoice sho�ving business name, address, license number and detailed <br /> costs of installation and matFrial,. [CONTRACTOR]. Nofe: No rebate v✓i!1 exceed the <br /> lotal cqst ol f��e inslallation o(the br�ck�vater prevention device work. i <br /> i <br /> •� A Vendor Paymenf Qptron Form si,yned by both the property owner and contractor IF � <br /> you would IikP the Ciry" of Gverett to pay the Contractor directly. Otheiwise, the rebate j <br /> chec ,tvill be made out and delivered to you_. ' <br /> �._ A completed and signed f=orm W-9 (Request for Taxpayer ldenlifcat�un Number and 1 <br /> Certitication) , <br /> . Page 10(2 <br /> l <br /> Rewsed OU+0912014 <br />