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I <br /> Backwater Prevention Device ; <br /> Property Owner Rebate Form , <br /> Backwater Prevention Device Rebate Form <br /> � <br /> Prrnt and return this forru �a�ith your e1bate package " � <br /> ,��' y�9��',/iK � I , <br /> Property Owner Name: �c r7H�e� – <br /> Property address: _�-f_�l ra�- � ��• ; <br /> City: ����l�ir-e.�� _State: ��' Zip: �v�--br i <br /> Mailing address (if differenl): � � <br /> City: State: —_-_ Zip: <br /> Email address; Phone: ( ) <br /> Cost to install Backwater Prevention Device: S i <br /> Rebate Package Checklist <br /> Please check that ynu have compfeted and rncluded the following items in yaur • <br /> submissiai. Items rndreated as�CONTRACTOR]wil!bc:provided to you Uy your <br /> r.onfractrn�. • <br /> [� The compleled (3ackwater Preventron Device Rebate Form (this forrn) <br /> ❑ Map of the property wilh location o(installed Back�valer Prevenlion Device <br /> [CONTRACTOR] <br /> ❑ A r.opy of lhe completed Backtvater Prevention Devicc Final Installation Ciiecldist : <br /> [CONTRACTOR) <br /> [] �I he itemized invoice showing bu�iness name: �ddress, license number and delailed � <br /> costs o( inslallafion and mat�;rials. [CONTRACTORJ. Nole: No rebafe will exceed fhe <br /> toial cost ot the install�tion of the backwater�revention device work. <br /> �j � V���idorYayment Option For�n signed 6y both the property owner and contractor IF � <br /> you would like tlte Cily o(Everetl to pay the Contractor directly. Olherwise, the rebate ; <br /> cher.k v✓ill bc made oul and delivered to you. <br /> ❑ A compl��ted and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certification) <br /> PBQP. 1 O(2 <br /> � <br /> Hevised 09/04'"101�4 , <br /> i <br />