Laserfiche WebLink
Backwater Prevention Device <br /> "Pfr <br /> " <br /> � Pro ► <br /> p erty Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and return this form with your rebate package <br /> Property Owner Name: t _,NAPP <br /> Property address: Vi b- , A Ae. Si , <br /> LCity: 4 — - —State: GSA. Zip: _ <br /> , 1 <br /> Mailing address (if different): 51c1 1 5 Cc ii r)i?_, <br /> I <br /> " i <br /> Gity: V"c, �-�Zi��, ! State: � Zip: ��` �'`'`-f <br /> g <br /> Email address: Phone: ( LZ5 ) 7-q3---3e <br /> Cost to install Backwater Prevention Device: $ '15e.)0 O C <br /> I <br /> 1 <br /> 1 <br /> Rebate Package Checklist l <br /> I <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. 1 <br /> XThe completed Backwater Prevention Device Rebate Form (this form) <br /> Jam' Map of the property with location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> WA copy of the completed Backwater <br /> [CONTRACTOR] p Prevention Device Final Installation Checklist <br /> k <br /> i= <br /> IX,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 /> A Vendor Payment Option Form signed by both the property owner and contractor IF <br /> ou would like the Cityof Everett <br /> to pay the Contractor directly. Otherwise, the rebate <br /> check will be made out and delivered to you. <br /> 1 <br /> 7QA completed and signed Form W-9 (Request for Taxpayer Identification Number and <br /> Certification) <br /> Page 1 of 2 <br /> Revised 09/09/2014 <br /> 1 <br /> i <br />