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Backwater Prevention Device <br /> � Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and return this form with your rebatc package '" <br /> Property Owner Name: CZ����� r �--� . ���"��— <br /> Propertyaddress ���� 2uC�C-6L ��t <br /> c�c�: ��c��rr scace: w� z�P: 9ato� <br /> Mailing address (if different): S�ti'�2 0� c bc�c� - <br /> City: State: Zip: _ <br /> Email address: _��Gk �h�' ti ���ou, Covti� Phone: ( �125 )_s��1 • O)� <br /> Cost to install 6ackwater Prevention Device: $ "-7�� <br /> 3, 658 . 2 '3 <br /> Rebate Package Checklist <br /> Plcase check that you have completed and included the following items in your <br /> submission. Items indicated as(CONTRACTORj wilf be provrded.to you by your. <br /> r.ontrar.tor. <br /> [] The compleled Backwater Prevention Devir.e Rebale Form (tfiis(orrn) <br /> ✓��qap of the property �vith location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> �q copy of the compleled Back�vater Pre;vention Device Fina!Installatron Check(ist �i <br /> [CONTRACTOR] { <br /> ❑ iTl e temized invoice showin,y business name, address, license number and detailed � <br /> costs of install�tion and materials. [CONTRACTOR]. Note: No rebate will exceed the <br /> rot�l r.ost o(the insfallafion o(the backwater prevention device work. <br /> [�'A Vendor Payment Option Fonn signed by both the properly owner and contractor IF <br /> you would like the Cily of Everett to pay the ConUactor directly. Othenvise, the rebate <br /> check will I�e made out antl delivered to you. <br /> [-� completed and aigned Form W-9 (Request for Taxpayer ldenlification Nun�ber and <br /> Certification) <br /> Pagc 1 of 2 <br /> Revised 09/09l2014 <br /> I <br /> I <br />