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Backwater Prevention Device <br /> , Property Owner Rebate Form <br /> Backwater �Prevention Device :Rebate Form <br /> IPrint and return lhis form with your rebate package <br /> Property Owner Name: ���;� ���C�NL � <br /> ' I <br /> ProPerty address: _/Q�,� ��f�,� ����� <br /> City:;_� � '"t .r,-- _�State: � )ft Zip: � '' <br /> h1ailing address (if di(ferent): <br /> ��ty''— State: <br /> Zip. <br /> Email address: �, c� � ���_ phone: (��) ,li ; . i �{�1 <br /> I <br /> Costjto install Backwater Prevention Device: $ � �jOt� J J <br /> Rebate Package Checklist <br /> Please check that you have completed and induded the (ollo�ving rtems in your <br /> subrnlssion. Items �ndic�ted as(CONTRA�TORj ��ill be provided fo you by your <br /> confractor. <br /> �Th'e completed Qack�vater Prevention Device Rebate Form (this formJ <br /> j�'fvlep of the property with lo�ation of instalied Backwaler Prevention Cevice <br /> [CONTRACTOR� <br /> []�A copy oLthe completed t3aclnvater Prevention Device Final lnstalla(ion Checklist <br /> [CONTRACTOR] <br /> i ' <br /> ['f The itemized invoice sho�ving business name, address, license number and detailed <br /> cosls of installation and materials. [CONTRACTORJ. Nnte: No rebate �vill exr.eed f,5e <br /> �ota!CI st of the inslalla6on o(th.c backw»ter prevention device wo�k. <br /> � Vendor Payment Option Form signed by both the�property owner and contractor IF <br /> you wc�uld like the City of Evereti to pay lhe Contractor direcdy. Othenvise, the rebate <br /> check �will be made out and delivered to you. <br /> [�'(A completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certifiiation) <br /> Page 1 of 2 <br /> i <br /> Revised i09/09/2014 <br />