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Backwater Prevention Device <br />4zerr 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: 22/( 22n/b q'% <br />City: rie-eE'rT State: W,4__. Zip: O 20 <br />Mailing address (if diffe <br />City: <br />State: Zip:�� <br />Email address: �5� U to CJk, Phone: ( 2,r) 2'S2.2(o9(P <br />Cost to install Backwater Prevention Device: <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 />the completed Backwater Prevention Device Rebate Form (this form) <br />❑i,Wlap of the property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />EJ-A-'�(-`opy of the completed Backwater Prevention Device Final Installation Checklist <br />[CONTRACTOR] <br />[ he 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 />f(/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 />completed and signed Form W-9 (Request for Taxpayer Identification Number and <br />Certification) <br />Page 1 of 2 <br />Revised 09/09/2014 <br />