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\ <br />EY-'�I <br />1ETT <br />�� <br />Backwater Prevention Device <br />Property Owner Rebate Furrr� <br />Backwater Prevention Device Rebate Form <br />Print and retu�n this torm �,�ilii your r'ebate paclt�ge <br />Property Owner Name: ,�el� a `c,�l��sl. <br />Pr�perty addre�s: ?2 31 i✓�c �,ticj�I'� �e ___ __ <br />-T <br />City: ���,.r�`-� State: 1.J4 Zip: ��'--..�r-� � <br />'�t- <br />Mailing address (if di(ferert): <br />City: <br />Email address: <br />State; <br />Phone: <br />�z� <br />Cost to install Backwater Prevention Device: S �� c70. � <br />---1---- <br />Zip: <br />Rebate Package Cf�ecklist <br />Plcase cher.!< that you have r.^rnpfeted and mclude:l liie (o(lo�ving items in your <br />submissior�. I(ems indicated as (CONTRACTOR] �vill be provided to you 6y yo�u <br />contrar.br. <br />�+] fhe cnmpleted Baclna�ater Prevention Devir,e Rebate Form (lltis iorm; <br />�� fvlap of the property vdith location of installed L3achwaler Prew��lion Devir.e <br />[CONTRACTOR] <br />�J /� cop�� of Ihc wnipl�tud 13��ci<�.vntcr I'icv��ntii�r Uovicc Tiral Ir,st��llahun l;hec;iisl <br />[CONI'RE�CTOR] <br />�j�] ilie itc�mized invoice shnta�ing business name, adrlres�, ha�nsc� n�imber and delaile�l <br />r.r>sts nf insl:allation and matcrials. [CON'� F2ACTOR]. fJutc: iVo rebote �vill excr.ed fhe <br />lntral cost oI fhe installatfon �>I the bacla:�afer ��r��vention devicr. �vo�k. <br />'�;� j A Venilor Pr�yment Option Form signed by both the property o�vner and contraclor IF <br />you �•��ould like the City of Fverett lo pay the Contraclor directly. O�hervdise, the re�ate <br />check v✓ill be made out and delivered to you. <br />�N, A com�leted and signed Form VV-9 (Request for Taxpayer ldenli(ication NwnLe� anrl <br />Cettifir.ation) <br />Pnae 1 ct <^ <br />Rev�,sed OP;O9!7(114 <br />