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--� <br /> Backwate� Prevention Device <br /> Property Owner Rebate Forrn <br /> Backwater Prevention Device Rebate Form <br /> P�int anc�retum this form wrth your rebate package <br /> �--�.�-- -- - • <br /> �Pr.operty:0ivner_Name'; ��IY� an� Ey�n C ,tye6j'�V <br /> �-��� <br /> __Property address_; I l0 1 RuG�C-�y p,y� <br /> —__ <br /> C�tY:._,EVP��'e� state: Zi <br /> �_, ..W P�1--P-" `�9�2b� <br /> Mailing'atldress.(if.iliffeer nf):_! <br /> w-ty"`" '� State'c .�Zi <br /> -----�P�• <br /> �Email�add"ress: v S � � hone:.� � <br /> _�_1��� e bna� • covr+ �-�- �� � � �-�-b-15b(o <br /> Cost to install Backwater Prevention Device: $�Su� ,a���4y��ZO'�'y <br /> Rebate Pacicage Checklist <br /> Please chec'r, that you have complefr.d and included the follov�ing items in your <br /> submissron. Ifenis indreated as(CONTRACTOR) �:i116e provided to you by your <br /> r.�ntraclor. � <br /> ie completed Saclnvafer Prevention Uevic:e Rebate Form (this form) <br /> tilap of lhe property with location o(installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> i copy of the compleled l3ackwafer Provuntion Device Final InslaHaUnn Checklist <br /> [CONTRACTOR] <br /> �]��� emized invoice showing business namc, address, license numbor and detailed <br /> • �s�rt 'ts c�l tns(all2lien and materials. [CONTRACTOR]. Nole: No rr.bate wi!l r.xceed the <br /> totar cost ol the insfallation o(the backw��ter prevention device work. <br /> �VendorPayment Option Forrn signed by 6oth the property owner and contractor IF <br /> you �vnuld like thu City of [verett to pay the Conlracror direc�ly. Othenvise, thf� r��hate <br /> check will be made out and delivered to you, <br /> A completed and signed �orm W-9 (Requesl for Taxpayer ldentification Number and <br /> e ' cation) <br /> Page 1 of 2 <br /> Revised 09109i2014 <br />