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i <br /> ; <br /> Backwater Prevention Device : <br /> I�ropeirty Owner Rebate Form ; <br /> � <br /> Backwater Prevention I�evice Rebate Form i <br /> Pnnt and retum thfs form wifh your rebale package ! <br /> , I <br /> PropertyOwnerName: '�/;,.� ���i� ►v���L�c� t <br /> � <br /> Property address:��()�l �i f��_T �� � <br /> i <br /> Ci F�v�� 1 .� ` <br /> ry� �-`(— _State: ^�_Zip. � <br /> Malling address (if different): �O�' VEYNov� � � <br /> c�cy ��e�/P.v� s state: w�4 Z;P. g?� � <br /> ��� <br /> Email address:���✓..�. C��u .,� ��..�a :4,�».� I Phona: (1r�fu )�<�p –��+{ Z � <br /> Cost to install Backwater Prevention Device: S_ ? �!�(�. C� ' <br /> Rebate Package Checklist ' <br /> Pieaso check that you have completed and included the following items/n your � <br /> submission. /tems indicated as(CONTRACTOR]will be provided to you by your <br /> contracfor, ; <br /> he co pleted Backwater Prevention Device Rebate Form (this (orm) ; <br /> c <br /> ap of the property with location of installed Backwater Prevenlion Devica � <br /> (CONTRACTOR) ; <br /> W-+�copy of the completed 8ackwoter Prevenfion Device Flnal Installation Checklisf � <br /> [CONTRACTOR) , <br /> • lie itemized invoice showing business name, address, license number and detailed ! <br /> costs of installation and materials. [CONTRACTOR]. Note:No rebate will exceed the � <br /> total cosf of!he insfa!lation of the backwater prevention devlce woric. i <br /> VendorPeyment Option Fam signed by hoth fhe property owner and contractor IF � <br /> you would like the City of Everett to pay the Contractor directly. Otherwise, the rebate , <br /> check ill be made out and delivered 10 you. ; <br /> A completed and signed Form W-9 (Request for Taxpayer ldent�cation Number and ! <br /> ification) <br /> ' . Page 1 of 2 I <br /> I <br /> Rovised 09/09/2D74 � <br /> I <br />