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Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Prinf and return this form �vith your rebate package <br />Property Owner Name: O I-I --c e 2 _ <br />Property address: �0��__ �j'� 57. <br />City: E��cTi 3tate: W� Zip: S 8 Zui <br />Mailing address (if different):_ Z3�y � Lun�%;�LD A-�� _ <br />City: _�-1lC-�E-rT _ State: 1,., A _ Zip: Z U/ <br />Email address: `ic�I�r, S{e'i�,rr`�v�j�n„ r. N� F'hone: (`��S )��/S `�o=a <br />Cost to install Backwater Prevention Device: $ _ <br />Rebate Package Checklist <br />Please c/ieck thut you l�ave carrpleted and included the followiny items in your <br />subrtiissron. Rems iridicatr,d as (CONTRACTOR; wil! be provided to you by your <br />contractor. <br />:_] The campleted Backwater Prevention Device Rebate Fo�m (this lorm) <br />�J Map of the properly 4viih location of installed Backwaler Prevenlion Device <br />[CONTRACTOR] <br />�J A copy oE the r,ompleted Bac.k�a�atnr Pri�ventron Device Final Inst�llation Checklist <br />[CONTRACTOR] <br />(] The ilernized invoice showiny l�usiness name, address, license number -�nd rietailed <br />costs oi inslallation and rnaterials. [CONTRACTOR]. Note: No rebate ��✓i!I exceed 7he <br />fotal cost of the installatiai of the bar,lcwater prevenlion device v�+orlc. <br />❑ A Vendor Payment Op�ion Form signed by boih the property owner and contractor IF <br />you would like lhe City of Everett to pay the Contractor d:rectly. Ofherwise, the rebate <br />check will be made out and delivered to you. <br />[-] � rompleted and sin�ed I orm W-9 (Requesl for Taxpayer ldNntification Number and <br />Certifir.ation) <br />Pagc 1 of 2 <br />Revised 09i09%�� 1 �3 <br />