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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: <br />� <br />(City to Pr�vide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: A7A � T/N i�ip 1'TZ L � <br />Installation Address: � C3 % C. U L 8 Y �1 �C <br />Cily: I �%��-�—__ Stale: wA Zip: c7 L�c� 'v � <br />Mailing Address (rf diNe2n�J: <br />City: State: _ Zip: <br />Email:rhar'�,�Pr�fz� �Coy-+c.-�5'� , �» � Phone:l'!�5) ��r� - oG 7%� <br />Total Cost to In� �.� I Device (Irom contractorinvoice): $ �" J l"�� <br />I, lhe p•operty owner, request lo have the City o( EvereH Backwater Prevention Device rebate check <br />for lhe installation of Uie device at the above referenced property address be made payablc to, and <br />sent lo, Ihe vendor specified on the back of ihis form. By requcsling the rebate check be made <br />payable lo Ihe vendor, I agree to Ihe fotlowing: <br />1. I will not receive a rebate check direcUy lrom the City aF Everelt. <br />2. Assig�ing payment of the rebate to the vendor does not exempt me from Back�vater <br />PrevenUon Oevice Rebate Program requiremenls. <br />I autliorize lhe release of my rebale lo Ihe vendor listed on the back oi this form pending <br />approval oi the completed Backwater Prevention �evice rebale packet by Uie City of Everett <br />�� / /����� � . <br />� �__ `=� <br />Signature of Praperty Owner <br />D3 —c�S -�c�is <br />D�le <br />