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Backwater Prevention Device Rebate Program <br /> Vendor Paym�:nt Option Form <br /> Project Number. (Cily fo ProvideJ I <br /> Please complete both sides of the form I <br /> Properly Owner'Sectian: <br /> Property Owner Name: ���� IQ,Z ��. <br /> InstallationAddress: ZUZ > L�I h�+ <br /> City: L.�v'P lrl-TI State: Zip: � ��b ( <br /> Mailing Address(il diNerenQ: X -1 0� �."l��' �� ✓V W <br /> City:__-t u �� Slate:�,_Zip: �(J .�.� I <br /> Email: V}�1QYV5 l�nf"jr�l �O �` ? , �P�e:�[o0 0� -J f_12 <br /> Tot�l Cosl to Install Device(tro'm contractorinvoice): $ `�Snvi <br /> I, lhe property owne , request to have the City of Everelt Backwater Prevention Device rebale check <br /> (or the installation o(the device al the above referenced property address be made payable to, and <br /> Gent to, Ihe vendor specified on lhe back of lhis form. By requesting lhe rebate check be made <br /> payable to the vendor, I agree lo the following: <br /> 1. I will not receive a rebate check direcUy irom lhe City of Everett. <br /> 2. Assigning payment of'.he rebate to the vendor does not exempt me irom Backwater <br /> Prevention Device Re�ate Proc�ram requirements. <br /> I aulhorize the release of my rebale to ihe vendor lisled on Ihe back af lhis form pending <br /> approval of the compieled Backwaler Prevention Device rebate packet by the Cily o(Everett <br /> —f-f-t' � �� <br /> Signalure of Property Owner Dale <br /> � <br /> ,, <br /> \ <br />