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Backwater Prevention Clevice <br /> Property Owner Rebate Form <br /> Backwat�r Preventio� � Device Rebate Form <br /> Prinf and refurn this form with your rebate package <br /> Propertf Owner Name: _I� a�'I S 1 L���n� S B n <br /> �T <br /> Property address: �� 1.� �v(,�c PI �v'�- _ <br /> City: Cv�ett State: �_Zip: zU � � � <br /> Mailing ad�lress (if different): <br /> City: 5tate: Zip: <br /> Email address: Phone: ( ) <br /> Cost to insitall Backwater Prevention Device: $ <br /> Rebate f�ackage Checklist <br /> Please r.neck that you have completed and included the �ollowing items in your <br /> submission. Items indicated as jCONTRACTOR]will be provided to you by your <br /> contractor. <br /> ❑ The cornpleted Backwater Prevention Device Rebate Form (this formJ - <br /> ❑ Map oF the property with location of instalied Backwater Prevention Device <br /> [CONTRACTOR] <br /> ❑ A copy of the completed Backwater Prevention Device Final lnsfallation Checklist <br /> [CONTRACTOF2] <br /> ❑ The itertiizecl invoice showing busir,ess name, address, Ifcense number and�fetailed <br /> costs of installation and materials. [CONTRACTOR]. Note: No rebate wili exceed the <br /> total cost of the installation of the backwater prevenlron device work. <br /> [ A Venc.'or Payment Option Form signed by both the property owner and contractor IF <br /> y�u would like ttie City of Everett to pay the Contractor directly. Otherwise, the rebate <br /> check wiil be made out and delivered to you. <br /> ❑ A completed and �igned Form W-9 (Request for Taxpayer ldentification Number and <br /> Certification) <br /> Fage 9 of 2 <br /> Revised 09/09l2014 <br />