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i <br /> I <br /> , Backwater Prevention Device Rebate Program <br /> � Vendor Payment Option Forrn <br /> i <br /> ProJect Number: __(Ciry fo Provide) <br /> iPlease complete both sides of the form <br /> i <br /> ' Property Owner Section: � <br /> Property Owner Name:_.��•• 4. (,n.(,�„��y!4q�ps, t/ ___ <br /> � Installation Address: }� r1 Y�f y�� �LV� , 9 <br /> i ! <br /> iCity: ZVG9.�'CT State:��1 _Zip:�_— <br /> � Malling Address(!l dlllerenfJ: <br /> I <br /> i City: Stale: Zip: <br /> Email: Hll TG.�._.l��C. � �51����� C.QIr� _Phone:(�c0) 7 I� 5�0 I <br /> Totel Cosl to Inslall Davico (Irom conbecfor invoiceJ: $ �+� �(�� �� � <br /> II, the property owner, requesl lo have the City of Everett Backwater Preventlon Device rebate check <br /> � for the installallon of the devir.e�t the abnye referenr.ed property address be made payable to, and <br /> sent to,the vendor specified on ihe back of this form. By requesting the rebale check be made <br /> payable to the vondor, I agreo to the fotlowin�� <br /> 1. I will not receive a rebale check direclly(rom Ihe City ol Everelt. <br /> I 2. AssigMng payment of the rebale to lhe vendor does nol exempt me from Backwater <br /> Prevention Device Rebate Pmyram reyuiromenis. <br /> I aulhori[e the release o(my robate lo the vendor lislod on the back ol ihis form pending <br /> approvol ot iho comploted Backwaler Prevention Devir.e rebate packel by Iho Cily of Everelt <br /> �.- �y � � <br /> ISiyn ture of Properly Ownor Dale <br /> � <br /> I <br /> � � <br />