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Backwater Prevention Device <br /> Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Farm <br /> Print and return this form with your rebate package <br /> Property Owner Name: r . <br /> ��-� <br /> Property address: ' <br /> City: 'L—:—TT State: ^ �_Zip: ] <br /> Mailing address (if different); <br /> City: State: Zip: <br /> Email address: v , �e`;Vi Phone: ( c� }_ i <br /> Cost to installs Backwater Prevention Device: $ .� ,L} <br /> Rebate Package Checklist <br /> Please check that you have completed and included the following items in your <br /> submission. Items indicated as[CONTRACTOR] will be provided to you by your <br /> contractor. <br /> LQ--(he completed Backwater Prevention Device Rebate Form (this form) <br /> [.j ap of the property with location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> F_'"H copy of the completed Backwater Prevention Device Final Installation Checklist <br /> [CONTRACTOR] <br /> ( 'The itemized invoice showing business name, address, license number and detailed <br /> costs of installation and materials. [CONTRACTOR]. Note:No rebate will exceed the <br /> total cost of the installation of the backwater prevention device work. <br /> T A Vendor Payment Option Foran signed b both the <br /> g Y property owner and contractor IF <br /> you would like the City of Everett to pay the Contractor directly. Otherwise, the rebate <br /> check will be made out and delivered to you, l <br /> A completed and signed Form W-9 (Request for Taxpayer Identification Number and <br /> ication) <br /> Paye I of 2 <br /> Revised 09/09/2014 <br />