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Ad= Backwater Prevention Device <br /> Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and return this form with your rebate package <br /> Property Owner Name: t -5 AS <br /> Property address: 2:3)21 t) i tavi a;t1Ac <br /> City: r"-----1" S7r State: L -`Y _ Zip: c <br /> Mailing address (if different): <br /> City: State: Zip: <br /> Email address: Phone: (t.(22J, ) 339 <br /> Cost to install Backwater Prevention Device: $ 7C <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 /> e completed Backwater Prevention Device Rebate Form (this form) <br /> R-1 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 /> [CONT CTOR] <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 /> A Vendor Payment Option Form signed by both the 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. <br /> 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 />