Laserfiche WebLink
� <br />� <br />Backwater Prevention Device <br />Property C)wner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Piint and return this form with your rebate package <br />Property Owner Name-���������, Q� n�,�� <br />Property address: ,�j_-'�2-`� � �k,��� AV�- <br />City: F�,�{-� State: ��A Zip: 2} �-- <br />Mailing addres� (if different): <br />City: <br />State: <br />Zip: <br />Email address: �12 ��_�t,n��c�'�� rZe�- Phone: (�l?.=� )�C(�p�% <br />�,c> <br />Cost to install Backwater Prevention Device: 5�Z SC� <br />Rebate Package Checklist <br />P�ease check that you have completed and �nr.luded the foll�wing items in your <br />submissiort. Iterns indicated as jCONTRACTORJ will be prcvided to }-ou by your <br />confractor. <br />[�✓ The completed BaGaa�ater Prevention Cevrce Rebate Form (this forrn} <br />j-��Map oi the properly �vitii location of installed Back�vater Prevention Device <br />[CONTRACTOft) <br />� !1 copy of the cnrnpleted <br />[CONTRACTOR] <br />^ �' <br />Bar,k,ia�ater Prevention Device Final lnsfaHation Checklist <br />� The itemized invoice showing business name, address, license number and detailed <br />costs of installalion and materials. [CONTRACTOR]. Note: No rebate will exceed the <br />total cost of the instalfation of the backwafer prevention device work. <br />[�A Vendor Payment Option Form signed by both �tie property owner and contracbr IF <br />you would like Ihe City of Everett to pay the Contr�ctor directly. Othenvise, the rebate <br />check will be made oul and de�ivered to you. <br />[j A completed and signed Form W-9 (Request (or Taxpayer ldentification Number and <br />Certi(ication) <br />Page 1 of 2 <br />Revised 09/09/2Q 14 <br />