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k*". 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: .re % ' 0.\A \\ <br /> a <br /> Li 05 <br /> Property address: . , , f"'6 . #0 6 <br /> City: f State: UA- Zip: 61 K \ <br /> Mailing address (if different): <br /> City: State: Zip: <br /> Email address: Phone: ( ) <br /> Cost to install Backwater Prevention Device: $ ) s-cyo co <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 /> r] The completed Backwater F'revention Device Rebate Form (this form) <br /> Map of the property with location of installed Backwater Prevention Device <br /> [CONTRACTOR] <br /> D A 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 /> (i 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 /> I I 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 />