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- el/PA. ,...g <br /> Backwater Prevention Device <br /> Na;ia Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and return this form with your rebate package <br /> Property Owner Name: 4- 4 ` 4r -- ,,, _ . <br /> Property address: /,3e 2 7 . - .71.7,.4-4 ;�- , T.. 6-1:1-r_4:—/-/ 7j/4 . <br /> City: 5-1-/E-. ,E-,t State: _ L _ Zip: I 2 ) <br /> Mailing address (if different): .54-'7 L <br /> City: State: <br /> Zip <br /> Email address Phone: (%Z-$ <br /> Cost to install Backwater Prevention Device: $ 6 <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 /> a The completed Backwater Prevention Device Rebate Form (this form) <br /> aMap of the property with location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> A copy_of the completed Backwater Prevention Device Final Installation Checklist <br /> [CONTRACTOR] <br /> TrThe 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 /> Vendor Payment Option Form signed by both thero erf <br /> y owner and contractor <br /> you would like the City of Everett to pay the Contractor directly. herwse, the rebate IF <br /> checkill be made out and delivered to you. <br /> A 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 />