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' � Backwater Prevention Device <br /> '���T Property Owner Rebate Form <br /> Back.water Prevention Device Rebate Form <br /> Print.and return this fonn wifh your rebate package <br /> �P`pert}i'OwnerName`: Cq,nd.a.Pi �.. �r56n <br /> �Propertjr;address:� 17 ZP, 1zt,t�lce.r Qu� <br /> ��YY��___�Uvur.�-I' �State:_ . 'W Pr �Zip;�ZDL <br /> �Mailing address.(ifjditferenl):_ ►�IA" <br /> Gity:,�- -"_ State:_� .Zip:-� <br /> Email.atlilFess"�=_:J CCO�YSOh �' Y1'�Sn . CAH'��one;_(!}�S � a5 � a8ss <br /> Cosflto install Backwater Prevention Device: $ 2 � 'rj(3��(.7D <br /> Reb�te Package Checklist <br /> Please check thaf you have completed and included the lollowing items in your <br /> su6mission. Items indicated as(CONTRACTOR]will be provided to you by your <br /> confr�clor. <br /> ❑ The completed Backwatei'Prevention Devir.e Rebate Form (this form) <br /> L� Map of the property wilh location o( installed [3ackwater f'revention Device <br /> (CONTRAGTORj <br /> �] A copy o( Ih�: compleled l3ar.kwa(er Prevenlion Device Final Installation Cher,lclist <br /> [CONTRI\CTOR] <br /> I. � Ti'ie iteniized invoi:.e showing business name, address, liccnso number and detailed <br /> coslsi of inst;�llation and malerials. [CONTRACTOR]. Nole: No rebate wrll exceed the <br /> Io1a1 cosf of(he installation o(the b�r.kwater prevention devir,e work. <br /> �] A.Vendor Paymrnf Option Form signed by both thr: property owner and contrar,tor IF <br /> you v�ould like the City of Everelt lo pay the Conlractor directly. Olhenvise, the rebate <br /> r.hc:ck will be made out and delivcred to you. <br /> I I � �oinpleted and signed Form W-9 (Requesl for l axpayer ldentification Number and <br /> Certifjcation) <br /> Pagc 1 ol2 <br /> Rr.vised OO10912D14 <br />