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I <br /> Backwater Preve�tion Device <br /> r Property Owner i ebate Form <br /> Backwater Prever�tion Device fRebate Form <br /> Print and refurn this form tivifh yourrebate package <br /> Property Owner Name: /��a��.,�ti ��v��S�/� <br /> Property address: /�j Z � ,� _��� <br /> `� A <br /> City: / d�Pi� State: �i�'�' �G� �, <br /> .Zip: _ d , � <br /> Mailing address (if different): <br /> City:i State: ZiP: � <br /> Email address: C� ��m�u S • Phone: ( ��� �� �'j�l � <br /> � � <br /> Cost'to install Ba�kwater Prevention Device: 5 � 2 , 'SOd •�� ` <br /> i <br /> Rebate Package Checklist i <br /> Please check that you have cornpleted and included f e �ollowing items in your � <br /> submission. Items indicated as(CONTRACTOR] will be provided fo you by your i <br /> contracta. I <br /> Tfi'e completed BackwaterPrevention Device Re6ate Fonn (lhis (ormJ <br /> �� � <br /> �p of the property with locatiun of installed Backt later Prevention Device � <br /> [CONTRACTOR] I <br /> � A copy of the completed Backwater Prevenlion De�ice Final Installation Checklist <br /> [CONTRACTOR� , <br /> (�h� i,emized invoice showing business name, addr!�ss, license number and detailed <br /> r.osls of installation and malerials. [CONTRACTORJ. /�Iole: No rebatc �vill exceed fhe <br /> (otal cosl-o/the insfallation o(the backwaterpreventionl device work. <br /> A Vendor Payment Opfion Form signed by both the Iproperty owner and contraclor IF <br /> you would 6ke the City of Everett to pay ihc Contractor di r ec t ly. O t henvise, the re6ate <br /> check wili be made out and delivered to you. <br /> ❑ A cbmpleled and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certification) <br /> I' <br /> Page 1 of 2 � <br /> Revised,09/09I7.014 I <br /> I <br />