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i <br />Backwater Prevention Device <br />04.1 Property Owner kebate Form <br />Backwater Prevention Device Rehate Form <br />Print and return this form With your rebate package <br />Prop rty Owner Name: 1�rn�.a,(d /` fl e-uSDl'I <br />Property address: -&0-- Cat srt <br />City:'] E oe 1 e7tt1 <br />address (if different):_ <br />City.. <br />State,: <br />State: <br />Email;address: (.f ch CID—) itkaC. COVQ p <br />COStlt0 install Backwater Prevention Device: $ <br />Zip: 26/ <br />Zi <br />5nD ."' <br />Rebate Package Checklist <br />Please check that you have completed and included the following items in your <br />sub <br />rrii�sion .tems indicated as (CONTRACTOR) will bie provided to you by your <br />contratorr, <br />feted Backwater Prevention Device <br />L'I fvlap o the property with location of instaCed B; <br />[CO ACTOR] <br />c 0 A opy of the completed Backwater Prevention <br />[CONE k }60RI <br />Form (t11is form) <br />Prevention Device <br />Final Installation Checklist <br />W/Theitemized invoice showing business name, addrqIss, license number and detailed <br />costs o ins Ilation and materials. [CONTRACTOR]. i te: No rebate will exceed the <br />total co of the installation of the backwater prevention be vice work. <br />L�er\ vendo,• Payment Option Form signed by both the <br />You would like the City of Everett to pay the Contractor <br />check vill.be made out and delivered to you. <br />CON <br />ification) <br />and signed Form W-9 (Request for <br />owner and contractor IF <br />Otherwise, the rebate <br />Identification Number and <br />Page 1 of 2 <br />Revised 0610912014 <br />