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Backwater Prevention Device <br />Property Owner P.�bate Form <br />Bac9cwater Preventiom Device Rebate Form <br />Print and return this (orm with your rebate package <br />F'roperty Owner Name: _��lC'v�E. . I�y�C�$ <br />Property address: � 5 r� ��,� N�r}" 5�- • <br />City: �J-f�Tt�_ __ State: (�:� <br />Mailing address (if different): <br />City: <br />Email address: <br />State: <br />Cost to install Backwater Prevention Device: <br />Zip: �SZc� <br />_ Zip: <br />Phone: (�� 1 Z�i'3 -�{ 17 U <br />Rebate Package Cliecklist <br />Please check th��t you have completed and irlGuded the follo�ving items in your <br />submrssion. lferns indicated as (CONTRACTOR] tvil! Ge provided lo you by your <br />cor�tractor. <br />�' The compleled I3ar.kevater Prevention Device Rebate Forrn (this lormJ <br />,_� �ap of lhe property wilh location oi installed F3ackw�ter Prevention Device <br />[CONT ACTOR] <br />[,YA c:opy of the complet�d Rack�vator P�evention Uevrce Final fnstallation C1�ecklist <br />�CONTJ2ACTOR] <br />r�.]' h itemized 'Invoice sho�viny business namc, address, liceiise nunber and detailed <br />costs o( installztion and malerials. [CONTRACTOR]. Note: No rebat� will er,ceed lhe <br />tol,il �•osf of tf�e installation o(thc backwaterpreventiai dcvir,e �vork. <br />r�r.ndor F'aymefd Oplion Form sic�ned by bolh the property owner and r,ontractor IF <br />you wnuid like the Ciry of Everett to pay the Conlraotor direclly. Othenvi �e, the rebate <br />chec �ill be made out and delivered to you. <br />A completed and signc�d Form W-9 (Request for Taxpayer identification Number and <br />Certifir.ation) <br />Pa�e 1 �f 2 <br />IZevised 09l0�1/?014 <br />