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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form i <br /> Project Number. (City(o Provide) � <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ���eLV�eS P � �0.�'�ctVA V��n�✓1 <br /> InstallationAddress: ���� �A�bu �CI�UP� <br /> City: EJCYC� Slate: w� Zip: � �2� � <br /> Mailing Address(�f diNerent): <br /> City: State: Zip: <br /> Email: I'l�f�o(U��lcti�u�- @amail •��p Phone: (+}L5) Z-52-�q�o I <br /> U�7 <br /> Total Cost fo Install Devic�(Irom confraclorinvoice): $ _��D---- <br /> I, the property owner, request to have the City of Everetl Backwater Prevention Device rebale check <br /> for the instailation of the device at the above referenced property address be made payable to, and <br /> sent to, tlie vendor specified on the back of this form. By requesting the rebate check be made <br /> payable lo lhe vendor, I agree lo lhe following: <br /> 1. I �vill not receive a rebate check directly from the City of Fverett. <br /> 2. Assigning paymenl ot the rebate to the vendor does not exempl mc from 82ckwaler <br /> Prevention Device Rebate Program requirements. <br /> 1 aulhorize lhe release o(my rebate to lhe vendor listed on the back of lhis form pending <br /> approval oi the completed Backwater Prevention Device rebate packet by the City of EvereU <br /> � <br /> � �i-I -lS <br /> Signature of r erty Owner Date <br />