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Backwater Prevention Device Rebate Program <br />Venclor Payment Option Forrn <br />Projecl Number: (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />icstailation Address: <br />,C�'sQ.�/a k � <br />�'�/LP Gvlbc� Q� • <br />��:Y: ,�i�^e�f s����:�z�p:_�f�3 <br />Mailing Address (ifdilferenl): _�� 2q__ 1/i�� � ) ' ___ <br />Cily: �V`�J�K�. Slate: �/�/�"" Zip: L� �� <br />Email:���Q f� Cl��i'1'2'�L10�� �/�Jt� Phone� i�"� �-(�'� % I <br />Tolal Cosl lo Inslall �evice (frorn contracfor invoice): $_Q `bO�' � __ <br />I, the property owner, requesl to have tne Cily of Everetl 8ackwaler Prevention Device rebate check <br />for the installation of 1he device at Ihe above re(erenced property addressbe made payable to; and <br />sent to, the vendor specifed on the back of ihis form. By requesting the rebate clieck be mado <br />payable lo lho vendor, I agree to Ihe following: <br />1. I will not receive a rebale check direclly from the Cily o( Everelt. <br />2. Assi�ning payment of Ihe rebale lo �he vendor does not exempt me trom Backwalcr <br />Prevention Device Rebate Program requiremenls. <br />I authorize the release of my rebate lo the vendor listed on tlte back of ihis form pending <br />approval of the completed Backwator Prevenlion Dcvicc rebate packet by lhe City of Everett <br />C��-� � p�.�k-� � ro� 1 S <br />Signalure oF PropeMy Owner Date <br />