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. , , ` i <br /> � � Bacicwater Prevention Device <br /> Property Owner f�ebate Form <br /> Backwater�Prevention Device �Rebate Form <br /> Print ana'return this (orm wi(h yourrebate package ( <br /> ;Property Owner Name:�_�, 'Soh I�,.� <br /> ; Property address: _�tS (Z.�cke� �i„e j <br /> 'City': ��.Q��-4 _'State: I !� � Zip: $ aD � <br /> � <br /> Mailing address (if different): ; <br /> �'City: _ 5tate: � <br /> 'Zip: <br /> -Email address: Plhone: ( ) _ <br /> (:ost to install Bacicwater Prevention Device: $ Z,5(S� �lJu <br /> , ; <br /> i <br /> Rebate Package Checklist � <br /> Please ch,eck that you have completed ar�d included tfie (ollo�ving items in your <br /> submissiun, ltems indicated as(CONTRACTORj wi!!tie provided to you by your <br /> conh� ctoc <br /> The completed Back�vater Prevention Devrce Reb te Form (this form) <br /> (- Map of the property with localion of installed Back�ater Prevention Device <br /> [CONTRACTOR� � <br /> i <br /> � ' r.opy o(lhe completed BackwaferPrevention Deilice Final InstaRalion Checklisl <br /> [CONTRP,CTORj <br /> �]�t�emized invoice sho�ving business name, addrl ss, license number and detailed <br /> costs o(installation and materials. [CONTRACTOR]. lyote: No �ebate ivill exceed the <br /> total cost o/!he installation ot the backv�ater pret�enlia device woik. <br /> i ' <br /> �!i Vendor Payment Opfion Form signed by both the property owner and wntraclor IF <br /> you �vould like the Ciry of Everett to pay the Contractor directly. Otheiv✓ise, the rebate <br /> check ��diil be made out and delivered to you. I <br /> �completed and signed Form W-9 (Request for Ta�Cpayer ldentification Number and <br /> ertdication) <br /> i <br /> i Page 1 of 2 <br /> � <br /> i <br /> Rev�sed 09iG917014 I <br />