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Backwater Prevention Device <br /> � � Property Owner Rebat� Form <br /> ���Ec�rater Preventiom Devace Rebate Form <br /> Print and retum this (orm with your rehate package <br /> Property Owner Name: _ ��y�,-v� /-� , �-� �e� �b7Z <br /> Property address: ���/ � v y,., rj�� r c� <br /> City: �V� Y'e l I Gtate: LL�� • Zip: / O ��� � <br /> �ailing address (if different):.�65'� Z-�y ,S� �, C . <br /> .-, �. <br /> C�y: __Ji^, D�b7�) I S�� State: l,ivt. Zip: `o� � En <br /> Email address: Phone: L�.�� � �3</�31f-� I <br /> Cost to install Backwater Prevention Device: � oZ <br /> � <br /> Rebate Package Checklist I <br /> Please chech lhat you have complefed and included the following items in your � <br /> subm.rssion. Ilems indicated as(CONTRAC;OR] �vi/l be provided to }�ou by your <br /> con7actor. <br /> [y� lfhe �:ompleted Backwater Prevenlion Device Rebate Ferm (this fonn) <br /> �ja'Map of the propr-,rty with location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> ��copy of the completed Bacl<water Nrevention Device Final lnstallation Checklist <br /> [CONTRACTOR] <br /> [ � The itemized invoice showing business name, address, license numbar and detailed <br /> cosls of installation and materials. [CONTRACTOR]. Nore: No rc�bate will exr.aed the I <br /> fotal cost of the installafion of the backwater prevention device tivork. <br /> �� A Vendcr Payment Optian Fonn signed by both the property owner and contracior IF <br /> you v✓ould lik� the City of Fverett to pay the Contractor directly. Othenvise, the rebate <br /> r,heck will be n;ade r�ut and delivered to you. <br /> ❑ Fl completed and signed Form W-9 (Request for Taxpayer identification Num'oer and <br /> Ce;lifiration} <br /> Pzge 1 of 2 ; <br /> I <br /> I <br /> Revised 09/O9/20�4 � <br /> I <br />