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B�ckwater Prevention Device <br /> Property Owner Rebate Form <br /> Backwater Preventian Device Rebate Form <br /> Print and return this lorm with your rebate package <br /> Property Owner Name: DAVID HOFFMAN <br /> Property address: 1501 BROUWAY <br /> City: EVERET7 State: WA Zip: 98201 <br /> Mailing address (if different):�r�U•- 7!�u - - Z S .�-2 Z --- -� ` <br /> -1-�-� '.._ - _ _ _ <br /> Cityr^-/ �-- -- ._., State�-��/� . —� Zip:CG�i- Z1�' <br /> `���. - --- - <br /> Emailaddress:� G��r�� I��- C� ._^��'S�v1-' Phone:G�aO `�53 -7�p�� <br /> Cost to install Backwater Prevention Device: $ .-~_.__ - ---- -_� � J-� - - <br /> 1Rebate Package Checklist-• <br /> Please check that you I�ave completed and included fhe follo�ving items in your <br /> submission. Items indicafed as(CONTRACTORJ�vi116e provided to you 6y your <br /> contractor. <br /> ❑ The completed Back�a�afer Prevention Device Rebafe Form (fhis formJ <br /> L7 Map of the property witli location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> ❑ A copy of the completed Backtvater Prevenfion Devrce Final Installation Checklist <br /> [CONTRACTOR] <br /> O Tlie itemized invoice sliowing business name, address, license number and detaited <br /> costs of installation and materials. [CONTRACTORj. Nole: No rebafe will exceed the tofal <br /> cost of the insfallafion of the backwater prevenfron device work. <br /> ❑ A Vendor Payment Option Form signed by both the property owner and contractor IF <br /> you would,like the City of Everelt to pay the Contraclor directly. Olhenvise, the rebate <br /> check �vill be made out and delivered to you. <br /> ❑ A completeSLand signed Form W-9 quest for T�P yer ldenti(ication Number and <br /> Certification) \vh'C�- ,�h ('.a,,� a <br /> � Page 1 of 2 <br /> Revised 09f09/20 i4 <br />