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i <br /> i Backwater Prevention Device <br /> ' Property Owner i ebate Form <br /> BackwaterlPreventioa� Device Rebate Form <br /> Print and return this form witli your rebate package <br /> Property Owner Name: _ �,��Q i j y� �,p�� <br /> Propertyaddress:;__ �� ?j� �,(�Q-�(J� �� <br /> I <br /> Gih'' — �iV�(^e�_ State: I Zip; �� 70 � <br /> , <br /> Mailing addre'ss (ifjdifferenl): 7ZU _ �_ I i� ��- S <br /> City: _�11.1LE.. ��V�M-1 State: ' ldl�ZiP:9�5 f� <br /> Email address: � � (Gb1J� � �,(�V�p�hane: <br /> --�-�- I�_ �3q . 33► �f <br /> Cost to install Backwater Prevention Device: $ �Z,,��j(�. (.31� <br /> Rebate Packagei Checklist � <br /> Please r.heck Ih�f you have compleled and incfuded the following ifems rn your <br /> submission. Iler.is rndica(ed as(CONTRACTOR] will be provided to you by your <br /> confraci�r. � <br /> i <br /> [_ The completed R,ackwater Preven(ion Device Rebate Form (U�is fonri) <br /> [_�I Map of the prope!rty with location o(installed [3ar,k later Prevention Device <br /> �CONyRl1CTOR] � ; <br /> �_�J Lopy of the completed eaclna�a�er Pr�;vention Ue'icr. Final Instal;ra�ia� Checklisl <br /> (CON ,RF�CTORJ ! Y <br /> i � <br /> [ Th� ilemized invoice showiny husiness namc, add�css, licen; : number and detailed <br /> cosis of inslallation and materials. [CONTRACTOR]. Nnte: No rebafe �vil!exceed the i <br /> tofal cost o(fhe instadation of fhe Lar.kwater prevenfior� devicr, work. � <br /> I <br /> [�Vendor f'ayrnciit Oplrnn Form signed by both lh��pioperty owner and coniraclor IF <br /> you would like the Cily of L=verelt lo pay the Contracto directly. Olherwise, the rebate � <br /> check will be made qut and delivered lo you. � <br /> / <br /> (J�A comoleted and�signed (=orm W-9 (Request for Tazpayer ldenli(ication Nwnber and <br /> Certification) � � <br /> j Page 1 of 2 <br /> I <br /> Revisr.A 09/U9I20 i4 I <br />