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Backwater Prevention Device <br />Property �wner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and rotum this form wifh yourrehate packagc <br />Proporty Owner Name: �uu Guls � O�SGTf� <br />Property address:,�� l`vUKr� �Nv� <br />City: r%vrn�.�-t�i State: _i �� Zip: � 2 � _ <br />Mailing .iddress (if different): <br />City: <br />State: . Zip; <br />Email address: l�o(pfor-S�( �u«c«s�.l��� P,hone: (`i15 �2>�-�7oi �i <br />Cost to install Backwater Prevention Device: S <br />Rebate Package Checkiist <br />Please check that you have compleied and rncluded !he tollo�a�ing items in your <br />submission. ltems indicated as (CONTRACTOR] will be provrded to you by your <br />contractor. <br />[�The compieted f3ackwater Prevention Device Rebate Form (this form) <br />�!— 4ap cf the property with location of installed Backwater Prevention Device <br />�COf�RACTOR) ' <br />l� <br />[] A copy of the completed Back�vater Prevenfion Device Frnal Installation Cl�eddist <br />(CONTRACTOR] <br />❑ The itemized invoice shoveing business name, address, license number and delailed <br />costs of inst�.�llation and materials. [CONTR,' ^TOR] Note No �ebate will exceed fhe <br />totaf cost oilhe insfallation o(the backwater prevention devrce �vork. <br />j�A Vendor Payment Option Form signed by botfi the property owner and contractor IF <br />you wouid like the City of Everett lo pay the Contractor direcUy. Otherwise, the rebate <br />check will be made out and delivered to you. <br />[Cj'A completed and signed Form W-9 (Request for Taxpayer lde�tification Number and <br />Ceiiificatiun) <br />Page t af 2 <br />Revised 09/09/'1014 <br />