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/� <br />Ev <br />Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Preventioin Devcce Rebate Form <br />Print 8f7C� 1 F: �[1f17 !i�;s /orrrr 1:7�f7 }��«1 'BJBiE f)c3C�(c7f�P. <br />Property Owner Namc: _I �1L� it�vv� (�)l Sf IV <br />Propertyaddress: ����---.�U�7_eLl�t?_ _--t� --- <br />City: E-�:������_- ---- - State: _L~'+-1 Zi : � � <br />P _ ..�.Si�l � <br />Mailin� address (if dif`erent): <br />City: ___ ___ _ _ _ State: <br />Email address: <br />---- zip' -- <br />_ Phone: (��i �_ LSSX -z��S� _ <br />Cost to install E3ackwate� Prevention Device: S__ 2.�_�(5�__ <br />Rebate Package Checklist <br />Please check that you heve complefed and included the following iterrrs ni yo��r <br />submission. ltems indicated as (CONI-RACTOR) �vil/ he proi�ided to }�ai by your <br />cor�tractor. <br />__ I he cornp(eted Backwater' F'roi�enbor� Uevice Rebate Forn� (tfus formJ <br />-' ni,�E, of the pmpr�i iy with location of mstalled 13ackvd.�ter Prevention Devicc <br />[CONTRACTOR] <br />' A cu��y of (h�r ccni��Ieted Ra�:1tr�-�;1cr P��t�c:rLnn l)�;vice (�in,31 ln.,triilnf« �ri Ch�:cld�;t <br />jCONTRACTOR� <br />� <br />I �e i�emi�_eri !rvuic�� showing b�itiiness naniN, ��'.�ir�ss, liccnse nuin�er and demiled <br />cosis o( inst��ll�ih�>n :�nd malenals. [CGNTRACTOR] Mote f��u reb�tc n��U exceed 1he <br />tr>t,�! cost of the ins(allalion ol the backi:�ato� p���vention device �vor!<. <br />[_� Verrdur Payntent Optiai Form signed hy bnth the property otvner and contractor IF <br />yuu �vould lilce the Cily of Everett tn pay the Conlrac,oi direclly. Othen�aise, the rebale <br />check v dfbe made out and delivered to you. <br />�_' A cornpleted and siyned Farm W-9 (Requesl fnr i�xpayer ldentificaticn Numher and <br />Ceriifc�:tion) <br />�'ar;e I nf 2 <br />f:�„� q�-�1 Ja�r)y;�Ol:i <br />