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Backwater Prevention Device <br />Property Owner Rebat� Form <br />Backwater Prevention Device Rebate Form <br />Print and return lhis (orm with your rebate pacicage <br />Property Owiier Name: DAN FiORINE _ <br />Property address:� OMBARD AVE <br />City: EVERETT State: WA Zip: 98201 <br />Mailing address (if different): _ __ <br />City: State: _ Zip: <br />Email address: MEGA DAN'a�fAHOO.COM ` Phone: _ <br />C� I <br />Cost to install Backwater Prevention Device: $ �S(% C7� �, '�,LL <br />Rebate Package Checklist <br />Please check that you have completed and included the following items in your <br />submission. Jfems indicated as (CONTRACTOR] wiU 6e provided to you 6y your <br />confractor. <br />� The completed Backwaler Preventron Device Rebate Form (this form) <br />Map of the property with location of installed E3ackwater Prevention Device <br />CONTRACTOR] <br />copy of the completed Backwater Prevention Device Final lnsfallation Checklist <br />CONTRACTOR] <br />�The itemized invoice sliowing business name, address, license numbe� and detailed <br />�costs of installation and materials. [CONTRACTORJ. Note: No rebate wil! exceed the total <br />cosf o( the installation of the backv✓ater prevention device worl<. <br />i�—A Vendor Payment Option Form signed by both the property owner and contraclor IF <br />you would like the City oF Everett to pay the Contractor directly. Otherwise, the rebate <br />check will be made out and delivered to you. <br />0 A completed and signed Form W-9 (Request for Taxpayer ldenti(ir,ation Number and <br />Certificalion) <br />Revised 09l09/2014 <br />Page 1 of 2 <br />