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� <br />� <br />Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Pnnt ond �etum (his (orm with your rebate package <br />Property Owner Name: �►:`�.c�-e <br />Property address: <br />c�cy: _ r.; �.r- <br />Mailing address (if diFterent): <br />City: __ <br />Email address: <br />, u- {i <br />State: w� <br />State; <br />__ Phone: <br />rP: `�y3�p � <br />Zip: <br />Cost to insWll Backwater Prevention Device: $ L�SOU. Uu <br />Rebat:� Package Checklist <br />Please check that you have completed and included the following items in your <br />subrnission. /fems indir,ated as (CONTRACTORJ wr!l be provided to you by your <br />r.ontractor. <br />[/J�The completed Backv✓aterPrevert6on Device Re6ate Form (this form) <br />�'� N1aP of the property wilh location of instailed Backwater Prevention Device <br />['.'ONTRACTOR] <br />(!! A copy of the completed Hackwater PiE>vention Uevicc� Fira! lnstaflalron Checkl;sl <br />[CONTRACTOR] <br />�ihe ilemized inaoice sho�ving business name, address, license number and detailed <br />cnsis of inslallation and materials [CONTRACTORJ. Note: No rebate will exr,eed lhe <br />tofal cost ol the irlsfallafion ot the 6acinvater prevenlion devrce work. <br />[�Vendor Payment Option Form signed by I�oth the property ownor and contraclor IF <br />you would like the City of Everett to pay the Contractor directly. Othenvise, the rebale <br />check will be made out and deiivered to you. <br />[�j A completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br />Certification) <br />Page i of 2 <br />Revised Og/09/2074 <br />