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� <br /> Backwater Prevention Device <br /> � Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and retum this form wifh your re6ote package <br /> Property Owner Name: �t�1 Llv+'W Q <br /> Property address: �-1 DZ o C�,�Jp�Q .��� <br /> City� �I1.F:lT ----State• . lNA _Z(p: � c�!_. <br /> Mailing address (if different):_�� � 5 �Q�U.1 �(Z, <br /> City:��i� State: W1� Zfp: "f.0 <br /> Email address: _ Phone: ��� Z93�-3a� <br /> Cost to install Backwater Preventfon Device: $ r7�� � <br /> Rebate Package Checklist <br /> Please check that you have completed and lncluded tha(ollowing items in your <br /> submisslon. Ifems indicated as(CONTRACTORj will6e provided fo you by your <br /> contractor. <br /> �'Jfhe completed Backwafer Prevention Device Rebafe Form (fhis form) <br /> �Map of the property with locatfon of Installed Backwater Prc�vention Device <br /> (CONTRACTOR) <br /> �iA copy of the r,ompletc�d Backwater Prevention Devir,s Final lnstallation Checklrsf <br /> [CONTRACTOR] <br /> �The itemized invoice showing business name, address, licenso number and detailed <br /> costs ot installalion and malerials. [CONTRACTOR]. Note:No rebate wifl exceed fhe <br /> tofal cost of!he installefion oi the backwater prevention device work. <br /> A Vendor Payment Option Form signed by both the properly owner and contractor IF <br /> ou would like the City of Everett to pay the Contract�r dfrectly. Otherwise, the rebate <br /> check will be made out and delivered to you. <br /> �1 A completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certificadon) <br /> Page 1 of 2 <br /> Revised 0 910 9/2 0 1 4 <br />