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� <br />� <br />Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print�and refurn this form vritl� your rebate pachage <br />Property Owner Name: <br />Property address: �j�,� ,� / (S� C(/1/� <br />City, ���f� State: �lL_ Zip: ��� <br />Mailing address (if different): <br />City: <br />State: <br />Zip: <br />Email address: �S,crrc ,LQw�,r�JJOL.�a�� phone: (�) a(p�1- %�7G-rj <br />Cost to install Backwater Prevention Device: $ Z,�, Uj <br />Reba�e Package Checklist <br />Please check that you have completed and included the following items in your <br />submission. Ifems indicatod as (CONTRACTOR] will be provided to you by your <br />confractor. <br />�The compleled �ackwater Prevention Device Reb�te Fonn (lhis (orrn) <br />� Map of the property with location of installed (3ackwater Prevention Device <br />[�TRAC70R] <br />� A�copy ofthc completed Buclavaler Pre:venlion Devrce Final lnstallation Checklis� <br />[CO�TRACTORJ <br />�lie itemired invoice showing business name, address, license number and delailed <br />r,osls' o( instaliation and materials. [CONTRACTORJ. Note: No rehate wiU exceed :hc <br />lolal cosf of !he rnstall�tion ot Ihe backwater prevention device work. <br />(.� A Vendor' Payntenf Opfion'Form signod by both the property owner and contractor IF <br />you woulH'like the City o( Everett to pay the Conlraclor directly. Otherwise, the rebate <br />chr.ck wiil 6e made out �nd delivered to you. <br />Q A completed and signed Form W-9 (Reyuest for Taxpayer ld�nlification Number and <br />Certification) <br />Page 9 of 2 <br />Revised 091091').074 <br />