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Backwater Prever�tion Device <br /> E� Property Owr�er Rebate Form <br /> Backwater Pr�vention Device i�ebate Form <br /> Print and return thrs form vdith your rebate package <br /> Property Owner Nan-�e. ._�__�✓�y Lew. S' <br /> —� <br /> Property address: 1:- 't� l. o .^�-1��� �� <br /> City: [��,eu'e� State: �-e�� Zip: FS� _ <br /> Mailing address (if different): �GMti-�_ <br /> City: State: Zip: <br /> Emailaddress: L�,���i�/���s7�1�1lo1�x,l Phone: ( 5'Ls ) 7S`-Z736 <br /> � <br /> Cost to install Backwater Prevention Device: 5 2�5�0,�� <br /> Rebate Packa�e Checklist <br /> Please check that you have completed and included the fo!lowing items in your <br /> submission. ltems indicated as(CONTRACTOR] will be provided to you by your <br /> cnntractor. <br /> ❑ The completed Baclawater Prevenfion Device Rebate Form (this form) <br /> �� Map of the property v�ith lor.atiqn of installed Backv,�ater Prevention Devir,e <br /> [CONTRACTOR] <br /> [� A cupy of the contrleted 13ar.1<w,3ter Prevr:ntion Device Final lnsfallation Checklist <br /> [CONTRACTOR] <br /> �� The �lemized invoice showing business name, address, license number and detailed <br /> r.osts o( installation and malerials. (CONTRACTOR]. Note: No rebate �a�ill ex�.eed the <br /> total cost of the instal/alion o/the bar,kwafer prevention device work. <br /> ❑ � Verdor Payment Option Form signed by hoth the property owner and contractor IF <br /> you would like the City of Everett to pay the Contractor directly. Othenaise, the rebato <br /> check will be made out and delivered lo you. <br /> ❑ A completed and signed Form W-9 (Reyuest for Taxpayer ldentification Number and <br /> Certificalion) <br /> Page 1 0(2 <br /> Revised 09/09/7014 <br />