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��; Backwater Prevention Device <br />Prop�rty Owner Rebate Form <br />i <br />Backwater �Prevention Device jRebate Form <br />� ; <br />; � <br />Pnnt and retum thisi form �a�ith your rebate package ; <br />I <br />Property Owner Name: ��� � tJ� Smun� � <br />PropeRyaddress:i 17a� iy�n �» �Nr N✓e � <br />--� i � <br />City� � J�,r e 1 T' State: /i <br />"t <br />Mailing address (ifidiffereni): ' <br />Zip: �/'lf�7Q f <br />City:s:��ere// State: �/�%Zip: s�7�1 <br />Email address: _� Phone: ( a5 )�S 5' L S S� <br />� � � <br />Cost to install Bacicwater Prevention Device: $_ �,� �ov � <br />i — <br />� � <br />Rebate Package Checklist ! <br />Please check thaf you have completed and included the (ollowing items in your <br />submission. ltems indicated as (CONTRACTOR] will tie provided to you by your <br />��� . <br />�completed BacMn�ater Prevention Devrce Reb Ite Form (rhis form) <br />� of the property with localion of installed Backv�ater Prevention Device <br />Rf�CTOR] ' <br />�]" A cop�� of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] i <br />[,,�e itemized invoice showing business name, addr�ess, license number and detailed <br />costs of installation and materials. [CON7RACTOR]. lYofe: No rebate will exceed the <br />to(al c st ot the instalfation of the backwater prevenfion device work. <br />� <br />A Ven�i�r Payment Option Forrn signed by both thel property owner and contractor IF <br />you woS�I�like the City of Evereti to pay the Contractoridirecfly, Otherwise, the rebate <br />�chec �will be made out and delivered to you. • <br />com��leted and signed Form W-9 (Request for Taicpayer ldentification Number and <br />Certification) i • <br />; Page 1 0(2 <br />Revised 09/09l2014 <br />