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Backwater Preventcon Device <br /> F� � Property Owner Reb�te Form <br /> B�ckwater Prevei�tion Device 64ebatc� Form <br /> Print and reLirn this torm !aith your�e�bate pac!<age <br /> Property Owrer Name: .SuSA,J .So�c�2F� <br /> Property address: ���! U ��� � I . <br /> c�ry: �,���� State: w�-1- Zi : nt � . I <br /> p �S�G1_ <br /> Mailiny address (if difierent):_ <br /> City: _ State: . -- Zip' -- <br /> Email address: Sosc� s�c�r�-�-� J qwr:.��ccr,n-.Phone: (Zc`�n � �) S-11o� j <br /> Cost to install Backwater Prevention Device: 5 �I �J�Z� • (� C7 <br /> Rebate Package Cl�ecklist <br /> Please check that you iiave co�rtpleted and irduded G�e folfo�a�ing items in your <br /> submission. Items indicated as(CONTRACTOR] m�ill be provided to you by your <br /> contractor. <br /> he completed 8ac1<wafer Prevention Devir,e Rebate Form (this form) <br /> �� . d�) UI (f19 ��ODBI�S� 1NI��l :i1CLll.011 U(!f1S18�!i�C! �BCkY;Ri(9f �f!?!�BII:IOfI [lt!'dIC� <br /> [CONTRACTOR] <br /> ��7�opy of liie completed (3,�ckvdater Prevr.ntion Devire Final Installation Checi<i;sl <br /> [CONTRACTOR] <br /> ie Itemized invoice shovding business name, address, licensr, nurnf,cr and d��Ia,�Jed <br /> costs of installation and materials. [C�NTRACTOR]. Note: No reb;;te �.vi!I excccu the <br /> tetal c�st o(the installation of the Uackwatcr prevention device m�ch. <br /> ��Vendor Paym,�nt Option Form signE:d by both the property oevner and contrac'or 11= <br /> you �vould like the City of Everett to pay t'ne Contractor directly. Otherv��ise, ihe rebate <br /> checl< will be made out and delivered to you. <br /> � completed and siyned Form W-9 (Request for Taxpayer ldentification Number ard <br /> Certification) <br /> Pac= t of 2 <br /> Rcvised Q9109'2014 <br />