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Backwater Preve�tion Device <br />Property Owner Rebate Form <br />Backwa�er Prev�ntion Device IRebate Form <br />Ynnt and retum this (ornr u�lth yovr rebufe package <br />Properry Owner Name: <br />Property address: Z`I i>> v u�. (=� I N <br />City: _�'�CC�,_�T -- <br />Mailing address (d different):__ <br />_State ��A Zip; 01 ,Zc) <br />City: --- ---------- State: I_ Zip: <br />Email address: __ _ _ Pihone: (�) z �) -3�i0`{ <br />Cost to install E3ackwater Prevention Device: 5_j� J��� <br />I <br />Rebate Package Checklist � <br />F'lease check that you have complefed and included t!I o fnlloivmg ifems in you� <br />submission Items tndicatod as (CONTRACTOR] v�ill e provided fo you by your <br />canfract r <br />} The eomplete�i Baclnv�terYreventron Devic,e Reb te Form (thrs (nrm) <br />,�� �v� o( the property :•.dh location of install�d Back�v�ater Prevention Device <br />[CONTRACTORj <br />���py ot lhe completed E3+�clnvale� !'revenfion De ir,e Final Installation Cher.klist <br />[CONTRACTORj <br />j�;�emized mvoice showmy bu,iness name, add ess licensa nurnber •in�i del•�iled <br />r'osls o( installation and materials. (CONTRACTOR]. <br />tural co�t of t7ie instaflation ol the U�r.ln:vter preventic <br />t � A Vendor!'aymen! Opticm f=orm signed by hoth th <br />yuu �+�ould likc� the Ciry of Evr.rett to p�y the Contrar.tc <br />chec will be made out and delivered io you. <br />�_ J A r,omn!eted and signed Form 1�J-9 (Request (or 1 <br />Certi(ication) <br />Revised 091G912014 <br />�te� No rnbale will exceed Ihe <br />device ta�ork. <br />property ov✓ner and contractor IF <br />directly Othenvlse, the rebate � <br />Identifioation Number and <br />Page 1 of 2 <br />