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, <br /> ; <br /> . � Backw�ater Prevention Device <br /> � Pr«�perty Owner Rebate Form <br /> i <br /> � <br /> Backwater �re��ention �evice �Rebate Form <br /> � <br /> � <br /> Print and return this form with your rebate package <br /> Property�OwnerNarrie:�p�n�' <br /> � -- - � � �r�f <br /> IProperty�address � � �j��� ���j <br /> (:Cityii ��JQr,�r' f5tate';� (,�,� <br /> __ . .��_fZip:� Q (' <br /> �Mailiing•address(if,iliffer`ent): <br /> L��ty'� State: <br /> __�Zip. <br /> Email�address: Phone: ( � <br /> .�___^_, ___ ---__ <br /> Cost�to install Backwater Prevention Device: $_ z��(� + � <br /> I <br /> � <br /> Rebate Package Checklist <br /> P/ease check that you have completed and rncluded the �ollowing ifems in your <br /> subnirssion. Items indicated as(CONTRACTORJ will be provrded to you by your <br /> contracfor. � <br /> ' ie co pleted BackwaterPrevention Device Rebate Form (tl�is fonn) <br /> CON�p of the property with loc�lion of installed Backwater Prevention Device <br /> �TORj <br /> A ¢opy of the completed Backwater Prevenlron Uevice Fina! fnsfallation Checklist <br /> (CONTRACTORj <br /> _ he ilemized invoice r,riowing business name, addr�ss, licen,e number and detailed <br /> cos(s oF inslallation and materials. [CONTRACTOR]. Not�: No reGale will exceed the <br /> tota/cos f the installation o(Uie baclnvater prevenfion device �vork. <br /> � A Vendor Poyment Option Form signed by both the,praperly owner and contrac <br /> you w�uld like the City of Everett to pay the Contractor directly. Ofherwise, the rebate IF <br /> chec � i i be made out and delivered io.you. <br /> � completed and signed Form W-9 (Request for Taxpayer ldenlification Number and <br /> c:erti I• tion) <br /> i • Psge 1 0(2 <br /> � <br /> I <br /> Revised i 9/09/2014 <br />