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Backwater Prevention Device <br /> ' - Property Owner Rebate Form <br /> Backwater Nrevention Device Rebate Form <br /> Print and re�urn this form w�ith your rebate package <br /> Property Owner Name: ��� 11,V� � , � 05 � j" <br /> Property address: � � Q �� � �,(,(V J P{^ � ��� <br /> City: G� i/ � �°� State: � /�,_.Zip: ��� <br /> Mailing :iddress (if different): <br /> City: � I/ � "-ri . • l,f� z,o (� <br /> � <br /> Emailaddress:_ I � 1.�i�o7/hoc��n,,,l. �+ Fhone: �yas^)� i n S�`�7 <br /> �7'1 �- <br /> Cost to install Backwater Provention Device: S 2-i S� � — <br /> Rebate Package Checklist <br /> Please check lhat you have completed and included the tollowing rlems in ynur <br /> submission. Ifems indica(ed as(CONTRACTORJ will be provided to you by your <br /> contractor. <br /> [(r'i <br /> fh� compleled Backwafer Prevention Devicc Rebafe Form (fhis formJ <br /> �ap of the properry with location of inslalled Backwater Prevention Uevice <br /> (CONTRACTOR] <br /> [�A copy of(hc cornpleted Backw�afer Prevenfion Device Fina! Installafion Checklisf <br /> [CONTRI\CTOR] <br /> �he itemized invoice showing business name, addross, license number and detailed <br /> r,osts of instailation and malerials. [CONTRACTOR]. Note: No rebafe will excecd the <br /> total:cosf ol the insfallafion of the backwater prevenlion device work. <br /> :' i <br /> '�,; r�:Vendor/'ayment Option Fonn siyned by both the property owner and contractor IF <br /> you wnuld like tfie Cily of Fverett to pay Ihe Contractor directly. Otherwise, lhe rebate <br /> r,heck will be mado oul and delivered to you. <br /> �,A;a�clf�ipieterf and signed F�rm 1N-9.(Rr:q�est for_l=�x��eJslentiticaticm.IVurttbot and <br /> �i'rc i�arrorrj' -_ . . _. <br /> Page 1 nf Z <br /> Revisad 0910911014 <br />