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ll/05/2015 �2;01PM c;53536607 M4PLE GROV[ RV <br />11/Oi/2016 7:L1 PH FAI a:5J15177o CaGpLcll'� Pluubin6. Inc P�'E 04/�5 <br />QI 0005; 0000 <br />Back <br />Prinf end <br />Propony <br />Property <br />Backwater Prevention Device <br />Property pwn�r Rebate Form <br />Prevention Device Rebate Form <br />rhis form wrlif your rebere packapp <br />r N3me: � � (vp R� <br />:�- �nl Q ! � ,L.._ ��'--"—� <br />City; � �� <br />i <br />Mailing address (if <br />State: W� � <br />-----_... z�p: � <br />City: � <br />s�tc; <br />Emall ndtlres�; =l�—Z�p� <br />--�-, <br />` �-------- _� Phono: (u Z�j, ��{�j`= � <br />CoSt to instel� Bacloyater provention Device: 5 2- �J D;), ()� <br />Rebate Package Checklist <br />Y���se check rpat you have complefed and included the lvllowing items in your <br />suhmissioq, Itpms mdlcated as (CONTR,qCTOR] will bo provfded !o yvu by y�v� <br />cuntractor, <br />The comp� ed 82cktvplerProvontroR Dev;ce Re6afe Form (thrs form) <br />ap of the propetiy with location of Installed Backwater Prevention Device <br />ONTRq_C,TO�t] <br />�� �Dy o( the c�mpletoq Bockwat�r picvention Ocv(Ce F�rtal fnsfa!lalion Cho�k/ist <br />[CON7RACTORj <br />ha �temve invoiCe showing bU5in6sS naplC, addrr.ss, Iicensn num6er and detailed <br />coyta o{ i�;;talfa �bn and maleri[�Is. [CON7RACTORj, rlofe: No rebate will exceed tha <br />tota! rost ot the nstallation Ol the baokw�ter pR; VenlJ� device woik. <br />A Vendor r��ymr.nt Option Form s; ned h <br />you would like t1�e City of Evotclt to � Y both Ihe pr�parry ownor and �Antractor IF <br />check v n be made out and doliveren to yo Centractor diroctiy. Othenvlse, tho reeate <br />n cornpieied �nd signed Form av.g (Roques for Taxpayer identification Number and <br />rufictation) <br />Pape t af 2 <br />F��aed o&�qsizo�a <br />