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G, <br />Ev <<rr <br />3ackwater Prevention Device <br />Property Owner Rebate Form <br />Backwat�r Prevention Device RQbate Form <br />Pnnt a��d return this (nrm with your rebate package <br />Property Owner iVame <br />�il f �p �S ��' �-�.� / �er <br />� /Yle��6�r <br />Property address: �.z I Le� ��� ,(�rr`✓2 <br />City: � U �=r�-t� 5tate: (i �{� Zip: ��0 <br />Mailing address (if <br />City: �'ver-�.1�'� State: �✓ij' Zip: 0?(1 <br />Email address: � v� @ � �` i `� �`�'�' �d °'9 Phone: ( 4'J,T ) aJ„l� U I / ; <br />Cost to install Backwater Prevention Device: $ <br />Rebate Package Checklist <br />Please checic that you have cornpleled and inclu�led the follovding items in your <br />submission. Items indicated as (CONTRA�TOR] v✓r0 he provided to you by your <br />r,o�Y:racfor. <br />� The comol.;ted Backv.�ater Prevention Device Rehate Form (this form) <br />LJ Map of the property with location of installed f3ackwaler Prevenfion Device <br />[CONTRACTOR] <br />(J /1 copy of the completed Backwater Prevention Device Final lnstallation Cher.ldist <br />[CONTRACTOR] <br />� � Thc itemized invoice showing business name, address, lir,ense number and detailed <br />costs of installation and materials. [GONTRACTOR]. Note: No rebale will exceed the <br />total cosl ollhe insfallation ot tl�e bar.k�vater prevenfion device wark. <br />j] A Venda Payment Opfion Form sigited by both the properry ovdner and contrac(or i� <br />you would like the City of Everetl to pay the Contractor directly. Otherwise, the rehaie <br />r,heck vdill bc made out and delivered to you. <br />'] A complefed and siyned Form W-9 (Request for Taxpayer ldenlification Number and <br />Ccrtific;alion) <br />Page 1 of 2 <br />R��vi:=rd 09(09/2014 <br />