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Backwater Prevention Device <br />OE4YL Property Owner Rebate=orm <br />Backwater Prevention Device Rebate Form <br />Print and return this form with your rebate package `�j <br />Property Owner NamNDe: I C1 Cn- f /GCr-11KIi 81-14 tie <br />Property address:. 2I13 Iveyr A(z —__- <br />City: 0,167e 7'"l State: 1']/A' Zip: <br />Mailing address (if different): <br />City: __ <br />State: <br />Zip: <br />Email address: 1'-N I. I)IrI LL�r-(l,!N111 Id%one: Z1j2-',3/% <br />Cost to install Backwater Prevention Device: $ D,$-66 <br />Rebate Package Checklist <br />Please check that you have completed and included the following items in your <br />submission. Items indicated as (CONTRACTOR) will be provided to you by your <br />contractor. <br />P--fhe completed Backwater Prevention Device Rebate Form (this form) <br />2--map of the property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />U--AA copy of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] <br />ie itemized invoice showing business name, 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 the backwater prevention device work. <br />[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 />[ r completed and signed Form W-9 (Request for Taxpayer Identification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 0910912014 <br />