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i <br /> �� <br /> ; Backwater Prevention Device <br /> � • ; Property awner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Prrnt and return this form wifh your rebate package ! <br /> , Property Owner Name: ��A I� r �" � r9 ii/���� ��J <br /> Property address: _ � � / � � p c�>�P I��L L Qr /.� 1��= <br /> City: _ _ �— /�Pr-E '7` -/ State: 1�1i H _,Zip: � 2 � � <br /> Mailing a�ddress (if different): �-- <br /> � I <br /> . ��i:Y� __ .State: � Zip: <br /> '�Email address: Plhone: ( ) <br /> Cost to instalf BaGcwater Prevention Device: $ i <br /> � <br /> Rebate Package Checklist <br /> Please r.heck that you have complefed and rnduded the follo�ving items in your <br /> submission. Items indicated as(CONTRACTORJ �vill ie provided 10 you by your <br /> contractor. <br /> [�.]�The completed Backwater Prevenfion Device Rebaite Form (this form) <br /> ✓�I�ap of the properfy �vith localion of installed Backwater Prevenlion Device <br /> [CONTRP,CTOR] i <br /> �copy of the completed Sackwafer Prevenfion Deqice Finaf Ir�stallation Checkiist <br /> [CONTRP,CTORj I <br /> �The itemized invoice sho�ving business name, addr�ss, license number and detailed <br /> costs of inslallation and materials. �CONTRACTORj. ryole: No rebate will exceed the <br /> total wst nf the installation of the backtivater preventro device work. <br /> [�A Vendor Pa}�ment Option Fornt signeri by bolh ihe�property owner and contractor IF <br /> you would like the City of Everett to pay the Coritractor,directly. Otherwise, the rebate <br /> check ill be made out and deiivered to you. <br /> A corn��leted and signed Form W-9 (Request for Tazpayer ldentificalion Number and <br /> Certification) � <br /> ' � Page 1 012 <br /> I� <br /> i <br /> Revised 09lG9I2074 � <br /> I <br />