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Backwat�r Prevention Device <br /> a Property Owner Rebate F�rm <br /> F rm I <br /> Backwater Prevention Device Rebate o � <br /> Pnnt and return this (orm with your rebate packaqe ' I <br /> i <br /> Property Owner Name: �r �'� �—�S �- <br /> � <br /> Th s i � <br /> Prnperty address: 37� � �� <br /> City: �Il�c[� State: �_Zip: _ �P z o / <br /> Mailing address (if different): G���G � � � �� �✓. ���vn, /C r' ��� • <br /> ( � ! <br /> City: �'ti�"��-� e ,� State: �_Zip: ��� � i <br /> Ernail address: Phone: (�) ^� � — aG'f � <br /> Cost to install Backwater Prevention Device: $ � <br /> i <br /> Rebate Package Checklist ; <br /> Please chPck that you have completed and included tne iollowing items in your � <br /> submission. Items indreafed as jCONTRACTORJ will be provided to you by your � <br /> contractor. <br /> �/ i <br /> [�'The completed Backwater Prevention Device Rebate Form (this form) <br /> i <br /> ❑ I�t��i of the properly with locatiun o( installed Backv✓ater Prevention Device <br /> [CONTRACTOR] <br /> �]�py of the completed Bacla✓ater Prevention Uevice Final Installation Checklist <br /> [CONTRP.CTOR] <br /> ie itemized invoice showing business name, address, lic�nse number and detailed <br /> cosfs oi installation and materials. [CONTRACTOR]. Note: No rebate will exceed tiie <br /> tntal cost o(the instalfation of the backwater prevention device work. <br /> —F � n yendor Payment Option Fom� siyned by both the properry o�vner and contractor IF <br /> �vould like the City of Evereti to pay th.: Contractor directly. Otherv�ise, the rebate <br /> check will be made out and delivered to �nu. <br /> completed and signed Form W-9 (Request for Taxpayer ldentification Number and � <br /> Cerlification) <br /> Par�e 1 O('l. <br /> Revised 0 9/0912 0 1 4 I <br /> � <br />