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I <br /> I <br /> � Backwater Prevention Device <br /> , Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> i <br /> Print I'and return this lorm �vith your rebafe package <br /> Property Owner Name: .j,,,,, �J/, � <br /> Property address: 19L7 r9- /�9 4✓• c-rcr�c.�— <br /> � ,/ ( <br /> City:l_ l�vc/a7T� State: _ Li/� Zip: 9,P2C / I <br /> Mailing address (if differenl): 7��/U ��� ,ff /1,'� <br /> ��tY:!Mr�rtir�;'�/� �State: G✓i} Zip: ���70 <br /> Email address: io��s(� f'tufl���;,rt., ���� Phone: ( Y?� ►�/y- /iuS ! <br /> � � I <br /> Cost to install Backwater Prevention Device: $ 7 �5�� '�v i <br /> I � <br /> I <br /> Rebate Package Checklist � <br /> Pfease cl�eck that you have completed and included the lollo�ving i(ems in your � <br /> submission. ftems indicated as jCONTRACTURJ wil!be provided to you by your � <br /> contrar.tor. I <br /> The on•,pieted Backwater Prevention Device Rebate Form (this form) <br /> Map of the property with location ot inslalled Backwater Prevention Device <br /> [CONTRACTOR] <br /> ��opy of the completed Backwater Prevenfion Device Fina! Instaflation Checklist <br /> [CONTRACTOR] <br /> / <br /> [—iJ ih'e itemized invoice showing business name, address, license number and det�,iled <br /> costs of installation and materials. [CONTRACTOR] Note: No rebato will�3xceed �he <br /> total cost of the installation o(the backwater prevention device work. <br /> i' <br /> ,[�J A VendorPayment Option Fam signed by both the property owner and contractor IF � <br /> you �vould like the City of Everett lo pay the Contractor direcily. Olherwise, the rebate ! <br /> check will be made out and delivered to you. I <br /> � A compie:ed and signed Form W-9 (Request for l axpayer ldentification Number and <br /> Ce ifcatiun) <br /> IPage 1 of 2 <br /> � <br /> I <br /> Revised 09f0912014 <br />