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� <br />Bar,kwater Prevention Device <br />Pr�perty Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Prinf and return this lorm �vith your rebate package <br />Property Owner Name: �Vfcw/�� ��� �i • Cd <br />Property address: <br />I'Y — � <br />z9c7 <br />City: ��Z��'� State: li�/� Zip: c7�G� <br />Mailing address (if different): S�rv►G <br />City: State: Zip: <br />e✓E/ e... � <br />Email address:�i+a� �� �✓��^��� "���v Phone: c�) L5E—�3 C�G A�b <br />' G�� O <br />Cost to install Backwater Prevention Device: 5 � k 2 s�'���� <br />. �r, <br />/, /L/Z. Z'� ��,, <br />Rebate Package Checklist O� � F'�� �'?'"'z�� awnL✓ <br />Please check fhaf you have corripleted and induded Ihe following ifems in your ��' 3`� G"q � <br />t-,�,,,t,yw Vii43s <br />submission. Items indicated as (CONTRACTOR) �vill be provided to you 6y your � <br />contraclor. I ��'� �t 7µ'/ <br />� ♦ All / <br />j_'�e completed Backwater Prevention Devir.e Rebate Form (this (orm) ��� �� °`• �• ' <br />zl���ii' <br />�ap of ihe property with Ior,ation of installed f3ackwater Prevention Device <br />CONTRACTORj <br />(�copy of the completed Backwafer Prevention Device Frnal !nslallation Checklist <br />[CONTRACTOR] <br />f—' he itemized invoice showing busine�s name, address, license rnimber and detailed <br />cosls of installation and ma�erials. (CONTRACTOR]. Note. No rebale will exccAd the <br />total cos( of 1he instaNation of the backwafer preventiai device work. <br />(� A VendorPaymr.nf Option Fonn signed by boQi the property o�vner and contractor IF <br />you would like the City of Everett to pay the Contractor directly. Olherwise, the rebate <br />check will be made oul and delivered to you. <br />�completed and signed Form W-9 (Requesl tor Taxpayer ldenlification Number and <br />Certification) <br />Pagc 1 of 2 <br />Revised 09/09I2014 <br />