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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Forrn <br /> Project Num6er: _(Cify to Pro��ide) <br /> Please compiete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: �p r�2�}ja�t�,_ �r�3��e����� <br /> fJ5/F �iamond Ven-h}�eS LLL <br /> installalion Address:L2�_3 - /22�Col b�_f��c-�.r--�'�P��C - <br /> City:�u e�e++ __ - -----State:I�,Z�Z�p'_4$ZC?L — <br /> Mailing Address(iCdiNerent): 5�p� �-I J�Ictn L� Qnn� <br /> ciry:��rp�t state:�J�_zip: � 8 0103 <br /> Email: Nn� t'�Pr-!; a�° ���{-ie�- c�� Phone: (yz� Q -,�l_L�(Q$— <br /> !tr�si,ne <br /> Tolal Cost to Inslali Device (from contrac(orinvoiceJ: 5 �� �V "� <br /> I, lhe property owner, request lo have the Cily ot Everett Backw2ler Prevention Device rebate check I <br /> (or the installation o(ihe device al lhe above referenced property address be made payable lo, and <br /> sent to, the vendor specified on the back of lhis form. By requesting lhe rebate check be made <br /> payable to Ihe vendor, I agree to the tollowing: <br /> 1. I�vill no[ receive a rebale check directly from the City of Everelt. <br /> 2. nssigning paymenl of the rebate to the vendor does not exempt me from Backv�ater <br /> Prevention Device Rebale Program requirements. <br /> I aulhorize the release of my rebate to the vendor listed on the back o(this form pending <br /> approval of the completed Backwater Prevention Device rebale packet 6y the Cily of Everett <br /> l� - � � � y - Z�- ts <br /> �aWre of Prope wner Date <br />