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� <br /> i <br /> � . Backwater Prevention Device <br /> � Property Owner Rebate Form <br /> i <br /> Backwater Prevention Device jRebate Form <br /> ,� <br /> Print and retum this form with your rebate package i <br /> P�roperty'.Owner�Name: �1.71-�c,..., + �,���:��v �c�i�„ <br /> V:: <br /> � i - <br /> Property address: 10•� ����„�.) �,'s � <br /> I <br /> ' <br /> City:-? �.'�✓,�} (State:-��W:� Zi� c� '�1 <br /> P� _i_c�_ <br /> Mailing•address (if diff�arent): (�..1`� l->w;.-,�� �V� <br /> i„����y.:-' �iJave{� State• 'L'�`� •Zip:r �j�Zu� <br /> Email�addre`s5: �oTa.'�.1�3�-jv..��„1. c...-, [P_hone:�( S�� ) �c19- �.'�l <br /> �aa <br /> Cost to install Backwater Prevention Device: $��50 C)• <br /> I <br /> Rebate Package Checklist <br /> Please check that you have completed and included fhe (oflotving items in your <br /> submissron. I(ems indicated as(CONTRACTOR] will be provided to you by your <br /> corrtra�tor. ' <br /> �� <br /> �The compleled Backwater Prevenfion Devrce Rebate Form (tltis form) <br /> / I <br /> � fv?ap of the property with toc�.lion o( installed Backwater PrevenUon Device <br /> [CONTRACTOR] <br /> j' ; <br /> �] A copy of the completed Baclavater Prevention Device Fin�� Installation Checklist <br /> [CONTRACTOR] � <br /> �� ilemized invoice showing business name, address, license number and detailed <br /> costs of installation and materials. [CONTRACTOR]. Note: No rebatc �vill exceed the <br /> tolal cost of the installation of tf�e backv✓afer��revenGonldevice worlc. <br /> ' i <br /> A Vendor Payment Option Form signed by hoth lhe �property owner and contractor IF <br /> �ou would like the Ciry oi Everett to pay the Confrector i ireclly. Otherwise, lhe rebate <br /> check will be made out and delivered lo you. <br /> Y A completed and signed Form W-9 (Request for Ta�payer ldentification Number and <br /> Certi(icalion) � <br /> i Paye 1 of'l. <br /> i <br /> � <br /> Revised 09l09I2014 I <br />