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I <br /> � Backwater Prevention Device <br /> � Property� Owr�er Rebate Form ; <br /> Backwater Pr�vention De�.�ice Rebate Form � <br /> Prrnt and return t1ii; icrm :vi�l; your tet;�tc- packaga <br /> Propcity Owrer Name: ' U�"''�'� �'-x' G'• G'lu Pi""`f'��� _ <br /> Property address: __ �4C�3 �ia�� ��)1-' _ ` <br /> Cll �"�.i,�'!�� $�BtC: �/�.�� ZI I��� I <br /> y� _--�_ -__ _ _ �• ---- <br /> Mailing address (d drfferentl:�___,__ __ ___ _.__:_ �, <br /> i <br /> Ciry: ----- -- --- ---- State: - - ---Zip: -- <br /> Emailaddress: Phone: uL ' Z��z" �" <br /> - - ------ �-�-�- 5F5��- <br /> Cost to install Backwater Prevention Device: S ` , ✓�U � �' <br /> Rebate Pac{;age Checklist <br /> 1'IFase �:heck tha! ;�c�i irav�� �.�nmpleted and rncluded the (oUow�ng items !n ;our <br /> subrnissron. lterns indica?�:d as(CONl-RACTOR) �vill be provided to you by y�ur <br /> r,ontr�r.for'. <br /> � <br /> ,�he completed Badnvater Preventron Uevice Rebate /-orm (this (r,rm) <br /> ��p of the ��roperty v��i'h lor.��tion of inslalled Back�rater Pieventinn Dnvice . <br /> [CONTRACTOR] <br /> �,�ipy of thr: couipleted Cl��cRwater Pravention nevice Prn,�l lnstallafion Cl�ecklist � <br /> [CONT ACTOR] <br /> � ; The iterni�ed invnice shnv�ing business name, adriress, license number and detailed <br /> ,,rr;;s u( inslallation �nd materials. [CC�NTRACTORj. Nutc: !dn rebate �^�ill rxr.eed the <br /> ;;;tr:/;�c�s. of the install�tion ullh�� back�•�ntr.r prevention dewce ��✓ork. <br /> y� Vc�ndor Paymerit Option Fonn signed t�y both the property own��r and conlraclor [F � <br /> �nc wouid like Ihe Ciry of Everett to pay the Contractor direclly. Othettvi,s, ihe rebate <br /> ��f�r:r;k�vill be made out and deli��ered to you. � <br /> jA ompleted and signed Form Vd-9 (Request For Taxpayer ldentrfication Number and ; <br /> �C��nification) <br /> r�;,�c ' �,t 1 � <br /> {�_�•.�.s:�..:1 L'9'0_l�::f�1.: �, <br />