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� � Backwater Preventic,n Device <br /> r Prop�erty Owner Rebat� Form <br /> i <br /> Backwater Preve�tion Device Rebate Form <br /> Print and return this form with your rebafe packa,qe <br /> �Property Owner Name: �qTT�eu/ Edl I�V`5 <br /> Property address: )3Z� ' E 1�l�r r �. Vi eu.� D� <br /> .City: ��e�� State: w/� Zip:��20� <br /> Mailing address (if different):_2�76y ��'c� live S� .�e <br /> r_ - <br /> City: �,4 �C.IK_5tate: �_Zip: q�'�z3 <br /> .Email addr'e'ss: ��q�J �u1 LomfqS�. I1�P�' Phone: (�) 251— 7�I 7 <br /> Cost to install Backwater Prevention Device: $ Z��J� <br /> i . <br /> Rebate i�ackage CheckliYt <br /> Please check that you have cocnpleted and included the following items in your <br /> submission. Items indicated as;(CONTRACTORJ will be provided to you by your <br /> contractor. <br /> The completed Backwater Prevention Device Rebate Form (this form) <br /> lap of the property with locfition of installed Backwater Prevantion Device <br /> [CON7RACTORJ ' <br /> A copy of the completed BaGkwater Prevention Device Final`lnstallafion Checklist <br /> [CONTRACTOR� <br /> [�T e itemized invoice showing business name, address, license number and detailed <br /> costs of installation and materials. [CONTRACTOR]. Note: /Vo rebafe will exceed the <br /> totaf cost of the installation o(tile backwater prevention device work. <br /> A Vendor Payment Option Form signed by both the property owner and contractor IF <br /> you would like the City of Everett to pay the Contractor directly. Otherwise, the rebate - <br /> check will be made out and delivered to you. <br /> �mpleted and signed Fotm W-9 (Request for Taxpayer ldentification Number and <br /> Certification) , <br /> � Page 1 of 2 <br /> Revised 0 9109/20 1 4 : <br />