Laserfiche WebLink
Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and return this form with your rebate package <br />Property Owner Name: <br />Property address: / %70 S A/D /c/,/,1 7- Sf IF <br />City:-5-y- eO 2+e .f f State: tf /4 zip: <br />Mailing address (if different): 3.S'D P . Sn.j /ii ' c <br />City: _L 5"'� 0- 4-1-1 a State: <br />Email address: <br />Cost to install Backwater Prevention Device: <br />_zip:,9f,'/y9 <br />Phone: <br />.4' 0 6 -3f0-S -g50S <br />Rebate Package Checklist <br />Please check that you have completed and included the folowing items in your <br />submission. Items indicated as [CONTRACTOR] will be provided to you by your, <br />contractor. <br />E2/The completed Backwater Prevention Device Rebate Form (this for <br />fvlap of the property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />dA copy of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] <br />![The itemized invoice showing business name, address, license number and detailed <br />costs of installation and materials. [CONTRACTOR]. Note: No rebate will exceed the <br />total cost of the installation of the backwater prevention device work. <br />dA Vendor Payment Option Form signed by both the property owner and contractor IF <br />you would like the City of Everett to pay the Contractor directly. Otherwise, the rebate <br />check will be made out and delivered to you. <br />dA completed and signed Form W-9 (Request for Taxpayer Identification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 09109/2014 <br />