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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (Cdy to Provide) <br /> Please complete both sides of tha form <br /> Property Owner Section: • <br /> � - --- <br /> Property Owner Name: /t�sSU/ .�Cr�SS�=�IYvi,^'` <br /> Installation Address: �i.��� ��c, l�+� __. <br /> Ciry: �`�''�'// State:� Zip: ��� I <br /> I Mai6ng Address(ildiflerent): <br /> I <br /> � Cily'. -- State: Zip: <br /> Email'--�rG�_� � 6 _ 5�t� c.�+�- Phone: (��'J)�8J`IP�� <br /> �l I/ <br /> Total Cost lo Inslall �evice (from contracfor invoice): $ :��I�y� 3 6 <br /> � -- – — <br /> I, lhe property owner, requesl to have lhe City oi Everetl Backwater Prevenlion Device rebate check i <br /> for 11•.e installation o(Ihe device al the above relerenced property address ba made payable lo, and <br /> sent to, Ihe vendor specdled on the back of Ihis form: By requesting the rehate check be made <br /> payable to lhe vendor, I agree lo ihe follov.�ing: <br /> 1. I will.not receive a rebale check directly (rom the Clly of Everetl. <br /> 2 Assigning payment of the rebale to Lhe vendor does not exempt me from Back�v;der <br /> Prevention Device Rebale Program requiremenls. <br /> 6authorize the release of my rebale to lhe vendor lisled on the back of Ihis form pending <br /> approval of lhe compleled Backwaler Prevenlion Device rebale packet by lhe Cily oF Everen <br /> �,��.-�,�-- ��_ <br /> Signalure of PropeAy Owner Date <br />