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� Backwater Prevention Device <br /> Property Owner Rebate For,m <br /> Back:water Prevention Device Rebate Form <br /> Print and reforn this form with your rebate package <br /> Prope�� Owner Name: R��ui�l TL (x,L���-- <br /> Property address: 5l2 Q�n«c%.��u� <br /> City:�vriv,N� �State; �it/!�- Zip: �IfJ�ZOI _. <br /> Mailing address (if different): �,�/7/ - iR��/� s-r-��i,{/ <br /> � / <br /> City: _j�,nrs��nr�( <br /> r St�te: _ !�A Zip• BZy� <br /> Email address: r�nc�,� �, ����t,� «,,�u,��-.iv�- Phone; (�) 25 y- p/p/ <br /> Cost to install Backwater Prevention Device: $__ 7j �p. 5v <br /> Reb'ate Package Checklist <br /> Please check thaf you have completed and induded 1he (ollnwing items in your <br /> submissior. Ifems indicated as(CONTRACTORJ tvill be provided to you by your <br /> contractor. <br /> ❑ Th'e cnmpleted Backwa(er Prevention Uevice Rebate Form (this form) <br /> ❑ Map of the properly wilh location of installed �ackwater Prevenlion Dovice <br /> (CONTRACTOR] <br /> ❑ A copy of the completed Badcwater Prevenfion IJevice Final lnstallation Cher,klist <br /> [CONTRACTOR] <br /> ❑ The itemized invoice showing business name, address, license number and defailed <br /> costs of installation and malerials. [CONTRACTOR]. Nole:No rebale will exceed Ih� <br /> total cost of tho instu/laticn ci!he 6ackwater prevention device work. <br /> ❑ AWendor Payment Option Form, signed by bolh th� property owncr and contractor IF <br /> you vyouid like the City of Evereft to pay lhe Contractor directly. Othenvise, the rebate <br /> check will be made oul and delivered to you. <br /> ❑ A cornpleted and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certifcalinn) <br /> ; Page 1 of 2 <br /> � <br /> Revisr.d 091091').014 <br />