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--� <br /> Backwater Prevention Device <br /> E��. Property Uwner Rebate Form <br /> " I <br /> B�rkwater Prevention I�evice IRebate Form <br /> Pnnl arta feturn llris form ���ith }�our rebate packaqe I� <br /> ( Property Owner Name; � � �-1- �J'��/�L <br /> —--�1�1-- �—�-7 --- <br /> � / <br /> Property address: __ � I / �_� �/�.P�Y� L�r /� !�!= <br /> I �� " <br /> City: __�_�.Q� 7 -1 � State: i�y_�_ Zip: � 2 � f <br /> Mailina �ddress (if different): ��— I <br /> ' — i — --- <br /> i <br /> . - City: ------ � State: Zip: <br /> • �-- _ -- <br /> '�Email address: „___ .piione: ( ) <br /> Cost to install Bacicwater Prevention Device: S <br /> Rebate Pacicage Checklist <br /> Please r.h�ck that you have corr�plero-:d��ncl included;he rcllcnr,iy it�:rr�s in your <br /> submission. lterns rndicated a�(CONTRACTOR] wil/be pro!�;ded to you by ;�pirr <br /> corltractor. <br /> [✓;. The compleled 13ack�vaterPrevenrion Device Peb�,te F��rrn (ihis (ornr) <br /> . (_✓�fvi�ap or the property �vilh lo,;ahon of installed Backavater Prevenlion D:��-�ce <br /> (CONTRF,CTOR] � <br /> / I <br /> I-�/� copy oi the r,onipleted t3ack��✓ater!'reverrtion Device Final InstalG:!ion Cha�;klrst <br /> [CONTRP,CTOR] I <br /> � �' Thr, iteniized invoice sho�ving busii�E�ss name, addrl ss, license number ar�d deiaiieri <br /> costs of insiallation and rnateiials [CONTRACTOR]. Note: Nn rebate vdill exceed rhe <br /> fot,71 cost n/the fnstallafion o(the hacln•rater prcventrori device �vorlc. <br /> ��A Vendoi Paymeirl Op(ion ! orrn si�ned by bnlh the!praperty owner and contrar.tor IF <br /> yo� �vould tike tl:e City of Everell to pay the Cni�iractor'dirertly. Othenvise, thr� rebate <br /> check Nill be made aut and delivered to you. <br /> (� � completed and sira��eci Form lN-� (Reyue;t for iaxpayer IJenlification Number and <br /> Ccrti(ication) <br /> � Pnce t ol2 <br /> f�ntised 0��('Oi:01�1 <br />