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. .� Z9�o / <br /> Backwater Prevention Device <br /> Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and return thi� (orm with your rebate package <br /> Property Owner Name: /i/��✓��� ��-�/• C� _ _ <br /> � // �f — � <br /> Property address:�// ft f7�i�� _ <br /> City: �v��f � State: �Zip: ��� � <br /> Mailing address (if different): 5���� <br /> City: Statc: Zip: <br /> Email address:L✓EbtA.jtlr��.�+�t Phone: 2S z�fi � "�73{� <br /> /Y/o6.Njl� iNe�E.(/.GC/h � �er.. <br /> Cost to install Backwater Prevention Device: S Z � �Z- � `'' � + �v� �6 �_a �.��v) <br /> OL b jcu� �wi�t�'I-7 ow�✓ <br /> Rebate Package Checklist ,� z;i 6,- �- tM.���iw �r393� <br /> Please check that you have cornplefed and incfuded the (ollov✓ing iterns in your �u'�� y�"' <br /> submission. Ifems indicated as (CONTRACTORJ tvil!6e pro��ided to you by your .�l�7 �I,,•,�," <br /> contracfor. � <br /> =�����/S" <br /> [✓fhe completed Backwater Prevention Device Rebate Form (this lorm) <br /> � oi Ihe property�vith location of installed Dackwater Prevention Device <br /> [CONTRACTOR] <br /> [�1C Copy of the compleled Rackwater Prevention Device Frnaf Installafion Checklist <br /> [CONTRACTOR] <br /> ��Ftf itemized invoice showing business narne, address, lir,ense tuunber and detailed <br /> cosls of inslallation and materials. [CONTRACTOR]. Note: No rebati� wiil exceed the <br /> lolal cost o((he insfallation of the bac6tivater prevenlion device worlc. <br /> ❑ A Vendor Payment Option Forrn siyned by both lhe property owner and coNractor IF <br /> you would like the City of[verett to pay the Contracror directly. Otherwise, the rebate <br /> check will be made out and delivered to you. <br /> A compleled and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certification) <br /> I'agc 1 ot 7 <br /> Revised 0 910 9/2 0 1A �,4li 1,�' <br /> i'r; <br />