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i <br /> _ I <br /> Backwater Preve;ntion Device <br /> � Pr�perty Owner Rebate Form ' <br /> � <br /> � <br /> Backwater Prevention Device�� Rebate Form � <br /> Pnnl and �otum lh�s lorm ;ti-�tl� your rebate F;;ir,kaye � <br /> Property Owner Name:.__1 1'/.��^—• - 1� �j���� ' <br /> " �11l1t r'_�_-i�-� � <br /> i <br /> � � — � <br /> Property addrr.ss: �%' �;� /1`_� �.:,._n� _'/,/!_ ; <br /> City: • '� !/ ,,.. ------ %.:' i I <br /> ---�--�_ ..—�.f , � .------ - State: . :i,:' ---ZiP: �. , <br /> __ , �_,. <br /> Mailing:a�dress (i6dlfferen� : /-'�f � : <br /> � --12.:�1----- -- ------ ! <br /> City: _ L�.L.:��_r'_1: _._ --._ State: ��_��_ --Z�p' �-�`� � '� ' � <br /> / � � <br /> Emai,l address: / •:: /i', . , '' -- <br /> -�-�u�LL.r_!.'L���''���c,.�1' P�hOl1C: (_��;i_�_:'`� , - ' <br /> - - ` "' i <br /> Cost to install Backwater Prevention Device: $_ '�- '�UU,UU I <br /> � 7` --------- -- - _ I <br /> I <br /> Rebate Package Checklist � ' <br /> /'lease check that you have r,oirip/eted and included fl�e (oliow�ng items in your <br /> �tibmission Items �ndir.afed as(CONrRACTORJ �vill be provided fo you hy yo��� <br /> r.onlrar,�or. � <br /> t <br /> ! {'1 hu complet�-�d t3ackwater I'rev��ntion Devica l2eba�te f-orm ('thLc (nrrn) i <br /> Ma'nf ihe io � rt ��-itli Inct�tion o(installed Rackw,�h r Prc.vention Devir.e I <br /> �-� I F p ' y � <br /> [CONTRACTOR� � ' ' <br /> ; <br /> ��� n �'��Py ��I �hr. r.on;plet�ed �3ackwnt��r I'revcnGnn Oev�r.e l mol lnst��ll�tion Cher.kbst <br /> [CONi RACTORJ � <br /> I <br /> (_� 1 I�e dr.rTuzed invo�ce :,ho�^�ing busm��::s name, .�ddri:ss, lia�nse nwnbei :.�nd detaded ' <br /> cast, of insl:ill:�tinn nnri maten�ls [CONTRACTUI2] I�ote No robale will nxcuedlhe <br /> tuf��l cn.sf n(fhe msl�llar�on �>r rnc har.ktvr�ler prevent�r�n�device work. � <br /> i <br /> � !1 Vendni Payment Ophnn F-��rm signed hy hoth ihe�p roperty owner and contractor IF <br /> you wc�uld likr, the City ol Cvei��tl to pay ihr� L'ontraGar Nirectly Olhenvise, ihc rehate ! <br /> r,heck will be made oul s�nd dclivered In ynu. � <br /> i <br /> �� coinpleled and ;,igned I orrn W_g (Rc,Guest (nr 1 azpay�r lden(ifica6on Numb�r and ' <br /> C tihr„�tion) <br /> � <br /> I � <br /> Page 1 of 1 � <br /> i <br /> f <br /> ReviseA 09�0�'2;i14 � . <br /> I <br /> I , <br />