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9 <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />, <br />Nroject Numher: _ (City to Provide) <br />Piease complete both sides of the form <br />Property Owner Section: <br />PrcpeAy Owner Name: �)��{^� V' � �� � �� �E ��. `���' � <br />Installation Address: s ����� �G �';'/ n `"'e <br />Ciry: � V� r,� l rt— State: I.V R- Zip: �� Z° � <br />Mailing Address (if diRerent): <br />City: State: Zip: <br />�Zr 2SZ - /�S'fr <br />6nail: __ Phone: ) <br />Tolal Cost to Install Oevice (from confractorinvoiceJ: S � L_(v- ��_� <br />p <br />1, the property o�mer, request lo have the City of Everett Backwater Prevenlion Device rebate check <br />(or ihe insla0ation of the device at lh� above referenced property address be made payable to, and <br />senl to, the vendor specified on lhe back of lhis form, By requesting the reb2le check be made . <br />payable lo thc vendor, I agree to the followinr�� <br />7. I will not receive a rebatr, check directly from the City of Everelt. i <br />2. Assigning paymenl of the rebate to Ihe vendor does nol exempt me (rom Dackwaler ; <br />Prevention Device Rebale Program requiremenls. � <br />I authorize lhe release of my rebate to the vendor listed on Ihe back of lhis (orm pending <br />approvai of the complelr.d Backwaler Prevention Device rebate packet by Cie City of Everett <br />( J /, ' <br />i� � /i,�"�".� �'" 25, �� <br />�f C <br />Signature o(,�Jfoperty Owner Date <br />