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Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and return this form with your rebate package <br />Property Owner Name: ) 4r , ^ tr <br />Property -address: -?9// 0 b_ _. A_ ,S <br />City: _!E�iJele4- <br />State: �..Zip; <br />Mailing address (if different) <br />City: State: <br />Zip: <br />Email address: Phone: 0 <br />( W25 <br />) - J ✓ 392 <br />Cost to install Backwater Prevention Device: $_ oL��_�� <br />Rebate Package Checklist <br />Please check thai you have completed and included the follov✓ing items in your <br />submission. Items indicated as [CONTRACTOR] will be provided to you by your <br />cot tr (for. <br />-E/The�6ompleted Backwater Prrt�enlion Device Rebate Form (this form) <br />the props ty with <br />-rnni location of installed Backwater Prevention Device <br />I.-_-f A copy of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] <br />(_ he itemized invoice showing business name, address, license number and detailed <br />costs of inslFillation and materials. [CONTRACTOR). Note: No rebate will exceed the <br />total cost of the installation of the backwaterprevention device work. <br />L A Vendor Payment Option Form signed by both the property owner and contractor IF <br />You would like the City of Everett to pay the Contractor directly. Otherwise, the rebate <br />check'wili be made out and delivered to you. <br />F/A completed and signed Form W-9 (Request for Taxpayer Identification Number and <br />Certification) <br />Faye 1 of 2 <br />Revised 09/09/2014 <br />