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Backwater Prevention Devic <br />Property Owner Rebate Forr <br />Backwater Prevention Device Rebate Form <br />Print and return this form with your rebate package <br />Property Owner Name:y L r QIF C-1 C5D� <br />Property address: ���_ 1'6 <br />City: — State: tAA —zip: �zo I <br />Mailing address (if <br />City: I Q / State: Zip: <br />Email address: _ 0000 1 S � `- 0AC- i (d phone: (Ws <br />Cost to install Backwater Prevention Device: $��Soa , <br />a roe/ <br />Rc�ate Package Checklist ��VUV v T �t53 <br />Please check that you have completed and included the following items in your <br />submission. Items indicated as [CONTRACTOR] will be provided to you by your <br />contractor. ��pwt; �ew✓ <br />5;?<e completed Backwater Prevention Device Rebate Form (this form) r,a I I <br />f'tallzty �tN <br />L� Map of the property with location of installed Backwater Prevention Device I / QQI/I Y- <br />[CONTRACTOR] <br />[� A copy of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] <br />F 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 />FJ A 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 />AfA completed and signed Form W-9 (Request for Taxpayer Identification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 09109/2014 <br />