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r �� <br /> Backwater Prevention Device <br /> Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and�eturn this form with your rebate package <br /> ��t•��c.l� �f� - <br /> Property OWner N:,me: KAY SHELIER <br /> Property addreos: 3206 NORTON AVE <br /> City: EVERErr _ State: WA Zip: 98201 <br /> Mailing address (if �iHerenl):P.O BOX 95 <br /> City:MUKILTOE State: WA Zip: 98275 <br /> EmailaddressmUk, Ik, fa.�,",��_ Phone��p���7I�`t' <br /> Cost to install Backwate►Preve on Device•�S� as� �� <br /> �'Rebate Package Checklist <br /> ��Please check thaf you have complefed and included the/ollowing ifems in your <br /> submission. Ifems indicated as(CONTRACTOR)will be provided to you by your <br /> contractor. <br /> '�The completed Backv�ater Prevenfion Device Rebate Form (lhis form) <br /> �LMap of the property with location of instailed Backwater Prevention Device <br /> [CONTRACTORj <br /> �A copy of the completed 9ackwater Prevention Device Final Installation Checklist <br /> [CONTRACTOR] <br /> � The itemized invoice shotiving business name, address, Iicense number and detailect <br /> costs of installation a�d materials. [CONTRACTORJ. Note: No rebafe will exceed fhe total <br /> cosf o/fhe insfallation of the backuvafer prevention device work. <br /> �A Vendor�aymenl Option Form signed by both the properly owner and contractor IF <br /> you would like ihe City o(Everett to pay the Contractc,r directly. Otherwise, the rebate <br /> check will be made out and delivered to you. <br /> ❑ A comp�eted and signed Fortn W-9 (Request for Taxpayer ldentification Number and <br /> Certification) <br /> Page t of 2 <br /> Revised 09/09/2014 <br />