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� Backwater�Prevention Device <br />Property Owner Rebate Form <br />i3ackwat�r Prevention Device Rebate Form <br />Print and return this (orm with your rebate package <br />Property Owner Name: l7AQR�A lL l.� N� _ <br />Property address: 2-(%1 O V 1iL(�iNW �,�., <br />City: ��(L�6•1 State: W�� Zip: v1�SZ� I <br />� Mailing address (i : ferent): <br />City: State: Zip: <br />Emai1 address: Phone: (`lZ�i ) 2-r�,t -�i3�3 <br />Costto install Backwater Prevention Device: $_ `�50�,0� <br />Rebate Package Checklist <br />Please check that you have completed and included the following items in your <br />submission: Items indicafed as (CONTRACTORJ tvill be provided to you by your <br />contractor. <br />fhe completed Backwater Prevention Device Reba;e Form (this (orm) <br />0 M p of the property with location of installed Back�vater Prevention Device <br />[CONTRACTOR] <br />�oy of the completed Baclna�ater Prevention Device Final Insfallation Checklist <br />[CUNTRACTOF2] <br />The itemized invoice showing business namP address, I�cense number and detailed <br />costs of installation and malerials. [CONTRACTURj. Note: No rebate wiU exceed the <br />fotsl cost o(. the installation of tire backwater prevention device work. <br />�Vendor Payment Option Form signed by boih the property owner and contractor IF <br />you would like the City of Everett to pay the Contractor directly. Othervvise, the rebate <br />check tivill be made out and delivered to you. <br />�completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br />Certification) <br />Page 1 of 2 <br />Revised nqlGg/�,� 1,1 <br />