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Backwat�er Prevention Device <br /> .� <br /> Property Owner Rebate Form <br /> Backwai:er I�revention C��evice Rebate For�n <br /> Print and return this form �vith your rebate package <br /> Property Owner Name: _ �(,<<...i C /��� �1�! S olV <br /> i'roperty address: 01.105 I—o�v�3 p.rz.n }��i; <br /> City: .� ��12.6a r-- State: J�j4- zip: . $2-O 1 <br /> Mailing addre:ss !iFdifferent): <br /> Gity: __ State: Zip: <br /> Email adJress: c.� Wi �Soi1 cn-�'ro�!' ov Phone: (��) 3D"3-05�5_ <br /> Cost to install Backwater Prevention Device: S Z _�0 .CS� <br /> Rebate PzcF;age Checklist <br /> Please check that you have completed and inciuded the f�llowing items rn your <br /> subrnission. ltems rndicated as�COA'7'RACTOR] will be provrded to you by your <br /> cont�actor. <br /> �he completed Back,wat�r Preventron Device Rebate Form (this forrn) <br /> ��lap of the property with location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> �/A copy of the completed Bacfaa�ater Prevention Device Fina! installation Checklist <br /> [CONTRAC70R] <br /> ��h� itemized invoice she�viny business name, address, license number and detailed <br /> r.osls .�f inslallation and materials. [CONTRACTOR]. Note� No rebate will exceed fhe <br /> tot�I cost o(the installation ol the bacicwater prevention device wor!<. <br /> [�A Vendor Payment Option Form sigr�d by both the property owner and contractor IF <br /> you would like lhe City of Everett to pay lhe Contractor directly. Otherwise, the rebate <br /> check will be made out and ,�elivered to you. <br /> � completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certification) <br /> Paye 1 0�7 <br /> Revised 09l09!<"Q14 <br />