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l <br /> , ; <br /> i <br /> Backwater Prevention Device Rebate Program � <br /> Vendor Payment Option Form � <br /> � Project Number ____„_____(Ciry to Provide) ; <br /> � <br /> i <br /> Please complete both sides of the form � <br /> I <br /> Property Owner Section: � <br /> i <br /> �� n�./�r—y✓� ; <br /> Property Owner Name' �i — - � <br /> Installation Address: ��1 Q � �, V E"S O� ��V� ' — � <br /> City: � �� 1�L=� State: w�' Zip: ��ZC� � ; <br /> � <br /> Mailing Address (il diHerent):��✓1� -'r� — t <br /> City: _ _ State: _� Z�P.� i <br /> Email: hu22V' OG�� Gn�P {� Y'GC�IG��(.� ��hon�(� )_ y2�.��=�'/ 77 � <br /> Total Cost lo Install Device (�rom contractorinvoice): $ _ — <br /> i <br /> I,the property owner, request to have the City of Everett Backvialer Prevention Device iebate check <br /> for the Installation of lhe device at the above referenced property eddress be rtlada payable ta, and � <br /> seN to,the vendor specified on ihe back of this form By requesting the rebate check be ma�e � <br /> payable to the vendor, I agree b the following ; <br /> 1. I will not receive a rebate check directly from lhe City of Everett. , <br /> 2. Assigning payment oi the rebato to ihe vendor does not exempt me from Ba�kwater ' <br /> Prevention Device Rebate Program requirementa <br /> — ---- ---. — — .- - ----- — - - i <br /> I authonze lhe releasc of �ny rebate ro thc vern �r listed on lhe bar.k ot this form pending ! <br /> approval o(the completed Ba�a r Prevenlion Device rebale packet by Ihe City ol Everett � <br /> : <br /> � <br /> �' I <br /> ' . /�-/� -/5 <br /> Signature o roPerty Owner Date <br /> I <br /> __ e <br /> — � <br /> � � <br /> � <br /> I <br />