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. Backwater Prevention Deaice <br /> � � Property Owner Rebate Fo�-m <br /> Backv�ater Prevention Device Rebate Form <br /> Print and return this form with your rebate package <br /> �obnr� d- '�G�,q l'��`So-i-. <br /> Proparty Owner Name: � ,�8—�9-�5�—�`''�`'� ozn�� '�-,; � '' na <br /> Propertyaddress: �(00�7 ����, t�gro� C{.ve <br /> City: � �c' r�tf State: �/� Zip: �l `�za 1 <br /> Mailing address (if different). 1�� �J•ox � �? 3� <br /> City: s�'S`�wv�r� State: W/} Zip: 5 F� 2 S 2 <br /> Email address: _ Phone: ( ) <br /> Cost to install Backwater Prevention De��ice: $ <br /> Rebate Package Checkli�t <br /> Please check !�iat you have cornpleted and rncluded the following items in your <br /> submission. liems indicafed as(CONTRACTOR] wifl be provided to you by your <br /> contractor. <br /> ,[] The completed Backwafer Prevention Device Rebate Form (this form) <br /> �j Map of the property with location of installed Bar• •ater Prevention Device <br /> [CONTRACTOR] <br /> [J7 A cory of the completed Backwater Prevention Device Fina;Installation Checklist <br /> [CONTRACTOR] <br /> [/] The itemized invoice showing business name, address, license number and detailed <br /> costs of installation and materials. [CGNTRACTOR]. No!e: No rebate �vill excead fhe <br /> total cost of fhe installation of the baclnvater prevention devir.e work. <br /> Q� A Vendor Payment Option Form signed by both the property owner and contracter I!F <br /> �you would like the City of Everett to pay the Contractor directly. Otherwise, the rebate - <br /> check will be made out and del�vered to you. <br /> JZJ A completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> 'Certification) <br /> Page 1 of 2 <br /> Revised 09/09/2014 <br />