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Backwater Prevention Device <br />4L 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: <br />City:. via—+ _ State: _ _ Zip: __ 96;2-C) 1_ <br />1 <br />Mailing address (if different): <br />i <br />City: <br />State: <br />Zip: <br />Email address: ��� j ,Phone: <br />Cost to install Backwater Prevention Device: $ 21 5 C1`6 r <br />Rebate Package Checklist <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. <br />ie completed Backwater Prevention Device Rebate Form (this form) <br />j ap of the property with location of installed Backwater Prevention Device <br />IINT <br />A copy of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] <br />1e itemized invoice showing business name, address, license number and detailed <br />costs of installation and materials. [CONTRACTOR]. Note: No re -bare :mill exceed the <br />total cost the installation of the backwater prevention device work. <br />Vendor Payment Option Form signed by both the property owner and contractor IF <br />you would like ihe City of Everett to pay the Contractor directly. Otherwise, the rebate <br />,ch.,:^k will be made out and delivered to you. <br />)- <br />A completed and signed Form W-9 (Request for Taxpayer Identification Number and <br />ertification) <br />Page 1'of 2 <br />Revised 09109/2014 <br />