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Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />I'nit� and return this ,•"::rm v✓itlr your re6ate pc�ck��ye <br />PropertyOwnerName: �C-12A�ril-{ •� �'�tz�No SfaP� <br />Propertyaddress: L-`-iCf{ 1,���11r�,A _ <br />City:�l.'f:(�'F Statc: �'�� Zip:.G��'2l�j <br />Mailing addr^.ss (if differenl): " __ <br />City: -- --------- --- State: ---- zi�' — — <br />Email address: _ . —_- Phone: ( ��25 ) `je�2-2231 <br />Cost to install Backwater Prevention Device: 5 2`7�U r_(ULl __ <br />— � --- <br />Rebate Package Checklist <br />('lease chec�s tl�at yo.: h���e cornpleted nnd rricluded fhe follo�ving items in your' <br />submisson. lfems indicated as (CONTRACTOR] t��ill be provided to you by your <br />conirar.tor. <br />(���hr, coniple[ed Rack::�.iter Prr3vnr�tion L)P�✓rce Reh;ale Fonn (lhis fnr'mJ <br />jjf:� nt the pioperty wdh lor,ation o( installed �3ackwater Prevention Device <br />(CONTRACTOR] <br />�L� ��'PY ��� ���� �-o�>>Pleted Backn�aterPievention Device Finaf InstaUation Checldist <br />[CONTRACTOR] <br />�i��e d��nuzr,d invoicr. ;howing business name, address, license n�imber ��nd detailed <br />�.osts ai inst�311ation .inc1 m�terials [CONTRACTOR]. Note: fJo rebate will exceed the <br />��nl��l eost o� tl;c insfntrar�on o� rne badaa�ater prc:ven(ion device �t�ork <br />�iJ A PV ndor Payment Op(ion Form signed by hofh ihe property owner and contrar,lor IF <br />ynu would Iike the City o( Fveretl to pay the Conirar.lor directly. Otherwise, the rebate <br />check �vill be made out and deliveied to you. <br />;U-A cen'pleled and signed Form VJ 9(Request tor Taxpayer ldenlification Number and <br />Ccitific�fion) <br />Paye 1 of 2 <br />Ri�viso-i U9tOSi:iU1.: <br />