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�%'�' <br />��„- <br />Ba�kwater Prevention Device <br />Property Owner fZebate �orm <br />Backwater Preventic�n Device Rebate For�n <br />Print ano'retum fhis form m�ith yourrebate package <br />Property Owner Name: P6ifi� 0. Smitk j <br />. 919 7foyt �vc. I <br />Property address: ,��zrcre,7Nas(wrgcm� 9B2o1 _ <br />� -- <br />City: _ _ <br />Mailing aiddress (if different): <br />City: __ <br />Email addr�s:>: <br />State: <br />State: <br />Phone: <br />- -- -- <br />-- — Cosfto install Backwate� Prevention Device: $_ <br />Zip: <br />Zip: <br />Rebate Package Checklist <br />('lease r.heck that you have completed and induded the (ollowing ifems in your <br />submission. ltems indicated as (COh'TRACTORJ ia-il! 6e provrded fo you by your <br />contrar,tor. <br />❑ The cumpleted 8ackwater Prevention Device Reba(e Form (this (orrn) <br />[✓fMap of the property vdith location of installed Back�vater Prevention Oevir.e <br />[CONTRACTOR] <br />I_I � copy of tne completed Backwater Prevention Devir,e 1=inal Instellation CF.eck!ist <br />[CONTRACTOR) <br />n The itemized invoice showiny business name, address, license number and detailed <br />costs of installation and materials. [CONTRACTOP,]. Note: No rebate will exceed the <br />rotal cost of the installation ol the backwate� prevention device wak. <br />❑ A Vendor Payment Option Form signed �.. �oth the property owner and contractor IF <br />you would like the City of Everetl lo pay the Contractor directly. Ofhenvise, the rebale <br />check will be made out and delivered to y�u. <br />❑ A completed and signed Form W-9 (Request for Tazpayer ldentification Number and <br />Certificati�m) <br />Page 1 r,( Z <br />Revised 0 910 9/2 0 1 4 <br />r `.�:�=j� ..T+,�� .�.", _::d;�.:d <br />