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�- <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Numbec (City fo Piovide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> ProperlyOwnerName: S�N^�- � JtN.+,��✓ - •i '�' _ <br /> InstallationAddress: IS�L �a.�ct�,' 1Q••- <br /> City: f vorl'f�{' Stale: '�/t� • Zip: 9�� 1 _ <br /> Mailing Address (iI diHerent)�_ <br /> Cily: Stale: Zip� <br /> Email: _ ___ Phone: ( ) _ <br /> Tolal Cost to Inslall•Device (Imm contracforinvoice): $ <br /> I,the property owner, request to have Ihe City of Everett Backwater Prevenlion Device rebale check <br /> lor Ihe installalion of Ihe device al the above re(erenced property address be made payable to, and <br /> sent lo, ihe vendor specified on Ihe back ot lhis form. By requesting Ihe rebate check•be made <br /> payable to Ihe vendor, I agree to the(ollowing: <br /> 1, I will not receive a rebale check direclly from the City of Everett. <br /> 2. AsslgNng paymenl o(lhe rebale to the vendor does not exempl me from �ackwaler <br /> Prevention Oewce Rebale Pro�ram rr.yuiremrnts <br /> ' 1 authorize the release of my rebate to the vendor lisled on the back ol Ihis form pending <br /> approval of lhe completed Dackwater Prevention Device rebale packel by the City o(Everelt <br /> , y zs-,5- <br /> ig ure of Praperty Owner Date <br />