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/ '_�� t <br />' E"�J�lIE3"% <br />� <br />Backwat��r Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and return this form v�ith your rebate package <br />Property Owner Name: KAY HOLLENBECK <br />Property address: 3702 ROCKEFELLER <br />City: EVERETT <br />Mailing address (if difterent) <br />State: WA Zip: 98201 <br />City: State: Zip: <br />Email address: Phone::�� J�y - G�o1 % �- <br />i-- ��L ^ <br />Cost to install Backwater Prevention Device: $�� w�� �`t'� <br />� �� fi1 -4—�,f <br />Rebate Package Checklist <br />Pfease check that you have completed and included the folfo�aing items m your <br />submission Ifems indicaled as (CONTRACTORJ �vill Ue provided to you by your <br />contractor. <br />❑ The completed Baclnvater Prevention Device Rebate Form (this (orm) <br />❑ Map of the pwperty with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />❑ A copy of the completed 8ack���ater Prevention Device Fina! Installation Cheddist <br />[CONTRACTOR] <br />U The itemized invoice showing business name, address, license number and detailed <br />costs of installation and materials. [CONTRACTOR]. Note: No rebate wil! exceed the folal <br />cost of U�e insfallation o( the backwaler prevenfion device �vorl<. <br />❑ A Vendor Payment Option Form signed by both the property o�vner and contrac;or IF <br />you �vould like the City of Everetl to pay the Contractor directly. Othenvise, the rebate <br />check �vill be made out and delivered to you. <br />� A completed and signed form W-9 (Request for Taxpayer ldentification Number and <br />Certification) <br />Page 1 oF � <br />Revised �9�09I2C74 <br />