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Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and return this (orm v.�ith your rebate package <br />Property Owner Na <br />Property address: <br />City: /i ��F',l'�i� �f State: _ji�Zip: � <br />Mailing address (if different): <br />City: <br />State: <br />2ip: <br />Email address: `I I'C�V e� {'YV4V e��/sl����Phone ( a5 )� S.2 - O/dh <br />Cost to install Backwater Prevention Device: S i� .�GS (XJ <br />Rebate Package Checklist <br />Please check that you have completed and included the follo�✓ing ifems in your <br />submission. ltems indicated as (CONTRACTORJ will be provided to you by your <br />contractor. <br />The completed Backwater Prevention Device Rebate Form (this lorm) <br />�Niap of the property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />7[�A copy of Ihe completed Backwater Prevenlion Devrce Final Installafion Checklist <br />[CONTRACTOR] <br />]' The itemized invoice showing business name, address, Gcense nwnber and detailed <br />costs o( installztion and materials. [CONTRACTOR]. Note: No rebafe v✓ill exceed fhe <br />to�al cosl of the installation of flte hackwater preventron device v✓ork. <br />D�Vendor Payment Option Form signed by bolh the property owner and contractor IF <br />you would like the City of Everett lo pay the Contraclor directly. Othetwise, lhe rebate <br />check will be made out and delivered to you. <br />��completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 09/09I2014 <br />