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� <br /> . i <br /> � Back�nrater Prevention Device <br /> � <br /> � Property Owner Rebate Form <br /> Backwater Preventiori Device Rebate Form <br /> Print and retum fhis form with youriebate package ' ' <br /> Property:Owne�Name: TE'r'Y P.. � ��-�-Pi�< Pv� __ <br /> , <br /> � i <br /> Property'address: /;.�c�7 �l/.� (' /cP.r �l5 P <br /> L-._--� I — <br /> Crtyy �-�IPn-P� St'ate: _I�.fZi�: ��L��/5-" <br /> (M`iling addres`s (if differen�): , _ <br /> C ty^A S�at�: iZip: <br /> �Emaii'address � rYP..I ��'7 �(�I1ta�P��s-f-, Pho�e: ( 4�;�5) c7Sa 4 ,(�� <br /> ---_. .�__,� �� �.:�G <br /> Cost to instail Backwater Prevention Device: 5 �2-� ✓��`� __ <br /> :� <br /> Rebate Package Checklist � <br /> Please check that you have completed and included tlie /ollotving ifems in your <br /> submission. Iterns indicated as(CONTRACTOR]wifl lie provided to you by your <br /> confraclor. ' <br /> v�The completed Badrwater Prevenfion Device Rebate Form (lhis ram) <br /> '� � <br /> � Map of the properly wilh location of instai�ed Back�Nater Prevention Device <br /> (CONTRACTOR] ; <br /> [�copy of the completed l�ack�a�afer Prevention Device Final Inslallation Checl<list <br /> [CONTRACTOR] i <br /> i <br /> �] The iten;;zed invoice showing business name, address, license number and delailed <br /> costs of i:istallalion and m�rierials. [CONTRACTOR]. Note: No rebate v��ill exceed the <br /> total cost of�he installation of the backwaler preventior� device work. <br /> �Vendor Payment Option Form signed 6y hoth thei properly owner and contractor 11= <br /> you would like the Cily of Everelt lo pay the Contractoq directly. Othenvise, Ihe rebate <br /> check`will be made out and delivered to you. ' <br /> �A compteted and signed Fnrm VU-9 (Request for Taxpayer ldenlification Number and <br /> Certificalion) j <br /> � Pac�e 1 of 2 <br /> � <br /> Revised 09l09/2014 � <br /> I <br />