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Backwater Prevention Device <br />(O:ram- Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and return this form with your rebate package <br />Property Owner Name: <br />Property address: Igc7rt f& i n iv,r Ave (%vwrc—I-f -Ja <br />City: _ State: Zip: <br />Mailing address (if different): <br />City: — State: Zip: <br />Email address: Phone: I 1 <br />Cust to install Backwater Prevention Device: <br />Rebate Package Checklist <br />Please check that you have completed and included the following items in your <br />submissi n. Items indicated as (CONTRACTOR] will be provided to you by your <br />contr or. <br />Th completed Backwater Prevention Device Rebate Form (this form) <br />Map of the property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />copy of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] <br />The itemized invoice showing business name, address, license number and detailed <br />costs of installation and materials. [CONTRACTOR]. Note: No rebate will exceed the <br />total cost of the insr illation of the backwater prevention device work. <br />�/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 />chZompleted <br />ill be made out and delivered to you. <br />and signed Form W-9 (Request for Taxpayer Identification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 09/09/2014 <br />