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� i <br /> Backwater Preve�ntion Device <br /> �' r Property Owner i ebate Form <br /> Backwater Prevention Device'Rebate Form <br /> Print anc�return this ,i�rm with your rebate package <br /> Property OwrierNa`me: _��('q�,/l� ��P�l�'� <br /> �--- -�..._�_y__.. <br /> �f?roperty'addi•ess: ZU�Q� �,I�.j i <br /> 1I � , <br /> LCity_�P�f State�_W � rZiP���,U�_ <br /> �Mailing a ress'(if different): 1 � j�� I��y�� <br /> City: -- � � I 1� �1 <br /> — .' �t � ,State: I W� fZip• � � <br /> �Email address; I p -}���`'I'��h: � Z06 1 �,Icy� _ 7 <br /> - -- . _.. , � �aCA 1�Oh� I Phott� ( 3 �5 <br /> . . —u— -r----- ----- <br /> Cost to install Backwater Prevention Device: $ ' ��� <br /> I <br /> Rebate Package Checklist � <br /> Please clieck fhat you have canpleted and included ti}e(ol/owing items in your <br /> submission. Items indreated as(CONTRACTORJ will be provided to,you by yo;ir <br /> contr Ctoi: I <br /> i <br /> I <br /> Th>�completed BackwaterPrevention Device Rebafe Form (this form) <br /> Map of the property with location of installed BackvJater Prevention Device <br /> [CONTRACTOR] <br /> ��J A coPY of the completed BackwalerPreventior� Det!ice Final InstaNation Cher,ldrsl <br /> [CONTRACfOi2] � <br /> LJ The itemized invoice showing business narne, aodrgss, license numberand detailed <br /> cosls of inslallation and materials. [CONTRACTCR]. Note: No rebafe wilf exceed the <br /> lotal cosf of the insfallation o(the bacinvater preve.�;tion�device work. <br /> � Vendor Payment Opfion Form signed by both the property owner and contractor II' <br /> you would like the City of Everett to pay the Contractor�directly. Otherwise, the rebate <br /> ch�ck will be made out and delivered to you. <br /> c�A completed and signed Form W-9 (Request for Ta�payer,ldentification Number and <br /> ation) <br /> Page 1 of 2 <br /> Revised 09/09/2014 <br />