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i <br /> Backwater Preverition Device <br /> �� Pro er� Owner Rebate For <br /> ��� p y m <br /> � <br /> �ackwater Prevention Device Rebate Form <br /> Pr;nt and retum thrs form with your rebate packaqe ! <br /> Property Owner Name: .J cw�, �s �/.Ic� �.v- <br /> �'-�:Tv.�.-:-s---_� <br /> PL„or pertY:address: ��l�/ 1J t�' ,S-� . <br /> � <br /> 'G�itq: . ��R� State: i (.��J ZipP �$2a / ^ <br /> i <br /> Mailing'adcJress (if different): � <br /> I <br /> CitY:' �Stal'e: i 'Zje. -- <br /> , ' <br /> Eroail�add�ess:� eJ, �-�e��:.� er,,;� e�,e,� �ihoneY (�/ZJ ) i 3- ��c� <br /> Cost to instal! Backwater Preventio� pevice: 5 2. ���� <br /> ��- <br /> i <br /> Rebate Package Checklist � <br /> Please check that you have r.omplefed and included the (ollowing items in your <br /> submission. Items indicated as(CON7RACTORJ wil! be provided to you by your <br /> contractor. I <br /> � ! <br /> ( • '� he completed Baclavater Prevention Device Rebate Form (this (orrn) <br /> T•'J' ap of the property with location of installed Backwater Prevention Device <br /> [C�NTRACTOR] <br /> '��:R�opy of the r,ompleted Baclrwaler Prevention De,vice Final Installation Checklisf <br /> [C:�NTRACTORJ <br /> � ; <br /> �'' , he itemized invoice showing business name, address, license number and detailed <br /> costs of installation and materials. [CC7NTRACTOR]. Note: No rebate wil/cxceed the <br /> total cost of the installation ot fhe baclnvater preventioi� device work. <br /> ` '�,A Vendor Payment Option Form signed by both the properiy owner and contractor IF <br /> y`ou would like the City of Everett to pay the Contractor directly. Otherwise, the rebate A <br /> check will be made out and delivered to pou. <br /> �' completed and signed Form W-9 (Request for Taxpayer ldentification Numtier and <br /> e'C rtification) , <br /> Page 1 0(2 <br /> � <br /> Revised 09/09/2014 � <br />