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Z�io 5 <br />Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and return this form with ),our rebate package <br />Property Owner Name: /Veg'*44Z)rz,(/- <br />Property address: 0'7- / r Z 7el- / <br />City: vtA-f VA _ State: Zip: 'zG <br />Mailing address (if different):5.ae'3-?&- <br />City: <br />State: <br />Zip: <br />Email address:G✓df&Aw &A.4o&APw- Phone: (Vzsr) z�� =3� <br />/r70NN�A /N e%C.V•Ge /h G 1 4. 20,1. 7b <br />Cost to install Backwater Prevention Device: $ <br />—r <br />0L. fw toa' Fprvjoe�f`, ow tav <br />Rebate Package Checklist r1�vovq'- UT39 sj <br />Please check that you have completed and included the following items in your Aq" c rct�/ <br />submission. Items indicated as [CONTRACTOR] will be provided to you by your <br />contractor. .1 f-}+t u <br />E The completed Backwater Prevention Device Rebate Form (this form) <br />❑ Map of the property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />A copy of the completed Backwater Prevention Device Final installation Checklist <br />[CONTRACTOR] <br />❑ The itemized invoice showing business narne, address, license number and detailed <br />costs of installation and materials. [CONTRACTOR]. Note: No rebate will exceed the <br />total cost of the installation of fhe backwater prevention device work. <br />F . j 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 />A completed and signed Form W-9 (Request for Taxpayer Identification Number and <br />Certification) <br />Page 1 of 7 <br />Revised 0910912014 <br />itll�{ <br />