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Backwater Prevention Device <br />0;�� Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and return this forrn with your rebate package <br />Property Owner Name: <br />Property address: <br />City: �Uf%�L"T%- State: X/�Y Zip: <br />Mailing address (if different): <br />City: <br />State: <br />Zip: <br />Email address: C ,J��r 2 Al" one (_ ) 3�0-��7 3 <br />Cost to install Backwater Prevention Device: $ <br />Rebate Package Checklist <br />Please check that you have cornpleted and included the following items in ycrr <br />submission. items indicated as [CONTRACTOR] will be provided to you by your <br />contractor. <br />tVThe completed Backwater Prevention Device Rebate Form (this forrn) <br />MllMlap of the property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />[copy of the completed Backwater Prevention Device Final Installation Checklist <br />[CD�NACTOR] <br />The itemized invoice showing business name, address, license number and detailed <br />costs of installation and materials. [CONTRACTOR]. Now: No rebate will exceed the <br />total st of the installation of the backwater prevention device work. <br />A Vendor Payrnent Option Form signed by both the property owner and contractor IF <br />you would like the City of Everett to pay the Contractor directly. Otherwise, the rebate <br />chec ill be made out and delivered to you. <br />A completed and signed Form W-9 (Request for Taxpayer Idenlification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 09/0912014 <br />