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�,�/�' Backwater Prevention Device Rebate Program <br />��/��,r Vendor Payment Option Form <br />� <br />Projecl Number. (Cdy to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />PropeAy Otivner Name: Blake Scott <br />Installation Address: 732 Colby Ave <br />City: Everett Slate: WA Zip: <br />fvlaiiing Address (il diNorent): <br />City: State: Zip: <br />Email: blakescoVV@vahoo.com Phone: (360) 927-3814 <br />Total Cosl to Install Device (Irom confractor invoice): S 3,822.00 <br />I, the property owner, request to have the City of Everett Backwaler Prevenlion Device rebate check <br />for the instailation of lhe devlce at the above reterenced property address ba made payable lo, and <br />sent to, the vendor specified on the back of this form. By requesting the rebafe check be made <br />payable lo the vendor, I agree to thc (ollowing: <br />1 I will not receive a rebate check direclly Irom the Ciry of Everetl. <br />2. Assigniny payment of the rebale to Ihe vendor does not ezempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I aulhorize the release o( my rebate to Ihe vendar lisled on Ihe back of lhis form pending <br />approval of the completed Backwater Prevention �evice rebate packel by Ihe Cily of Everett <br />'�����!�� O � J ! '� _ <br />ignature o( Property Owner Date <br />