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Fl� <br />Backwater Prevention Device <br />Property Owner Rebate Form <br />8ackwater Prevention Device kebate Form <br />Piin,' ;,nd re.rurn ti�is fcrm ::�ith your rebate package <br />Property Owner Name: '-50 �in� C3�,h- L <br />Property address: `� 3�3 �°�^"�'-�� —S� e <br />Cit �= `' e�' 2\Y State: l,.i /i Zip: `t ��� � <br />y' --- -- <br />Mailing address (i( differenl): <br />City: <br />Email address: <br />State: <br />Cest to install Backwater Prev�ntion �evice: <br />Zip: <br />Phone: ( y�� )'t� z- 1 G s y <br />Rebate Packa� Checklist <br />Ylease check that you liave completed 'dnd includc�l the (ollota�ing items in }�our' <br />,;ubmission. Items indicated as jCONTRACTOR] �:�ill be pr�vided to you by your <br />contractor. <br />(_. 1 The cornpleted Bac!<water Prevention I_)evice Pebat� Form (thrs fnrrn) <br />j] t�1ap of the property with location of installed Backwater Prevention Device <br />[CONTRACTflR] <br />�;__i ii cupy of the complei��d Ba�:ki'��iter Prever�tion Devir,e Fi�i��l lnsfa!ltafion Checklisf <br />[CONTRACTOR] <br />(] The itemized invo�cn s:h�nviny b�isiness name, address, license nurnber and detailed <br />cosls of installatiun an�i n��tr�rials. [CONTRACTORj. fJote No rebate will exceed the <br />total cost o( tho insfall�i;ion of the back�a�ater p�evenhon devir.e work. <br />[] � Vendor Paymei>t Option Form signed by both the property owner and contractor IF <br />you vdould like the City of C:verett to pay ihe Contractor direclly. Otherv,�ise, the rebate <br />check will be madc out and deiivered to you. <br />[] A completed and signed Form W-9 (Request fer Taxpayer ldentification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 091091<014 <br />