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� Backwater Prevention Device <br /> �� Property Owner Rebate Form <br /> B�ck�water Prevention Device �ebate Form <br /> Print and relurn this form with your rebafe package <br /> Property Owner Name: ,��Q(�� �� ►V�c"�� l�t V� _ <br /> Prcperty address: �S Z�'I ���t/ `1-\v'�- <br /> City: E�lc�'-e�� State: ��i Zip: � <br /> Mailing address (if different): S�� �'M-E <br /> City: � State: Zip: _ <br /> Email ad�iress: Phone: ( ) _ <br /> c_c7 <br /> Cost to install Backwater Prevention Device: 5 2-5 �' <br /> Rebate Package Checklist <br /> Please check that you have completed and included the followntg items in your <br /> submission. lterns indicated as(CONTRACTOR] will be provided to you by your <br /> contraetor. <br /> The ccimpleted Back�vater Prevention Device Rebate Form (this forrn) <br /> [�f i�4ap of ihe property wilh locatinn of insfalled Backv;aler Prevention Device <br /> [COyT'RNCTOR] <br /> �j A copy ot lhe compleled Qad<m�ater PieveNion Device Final Installation Checklist <br /> [CONTRACTOR] <br /> ;� I I�e ita�mized invoice showing business name, address, license number and detailt�d <br /> costs of ir�stallation and materials. [CONTRACTOR]. Nofe: No r'eUafe m�ill exceed the <br /> tntal cost of the installation of Ihe badavater preventiwi device tn�ork. <br /> ��A Vendor Payrnent Option Forrn signed by bolh the property owner and contractor 11= <br /> you �vould like the City o( Everelt to pay the Contractor direclly. Olhe�wise, the rebate <br /> �che k�wi�l be made out and delivered to you. <br /> completed and signed Form W-9 (Request for Taxpayer ldenlification Number and <br /> Certificalion) <br /> Pagc 1 of 2 <br /> Revised 09J�)9/201 d <br />