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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />ProJect Number. (City lo Provide) <br />PlPase complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Installation Address: <br />�' �?�crf�zt� T��,-���~ <br />Coz�y �lvr <br />Cily: C�L`x����- State: I( )� Zip: / d�J / <br />Mailmg Address (ildilferen!): �7 ���}' �/ yb' <br />City: 1U�,Gf��% — State: �� Zip: 7�� / <br />Email: �I��,�-,ll�� �.��tu,� a��� Pho�e: (�j �D�-� 15�6 <br />Total Cost to Instail Oevice (from canfractorinvoice): $ Z_ soo. ^� <br />I, the properly owner, request la hava the City of Everett Bnckwatar Provention device rebafo check <br />for tho instatiation of the devfce at the above referenced property address be made payabie to, and <br />sent to,lhr. vendor specdied a� Ihe back ot this form. By reqursting lhe rebate check be made <br />payable to Ihe vendor, I agree to the tollowing: <br />t. 1 wUl not receive a rebate aheck directty from !he Gily ol �verelt. <br />2. I�ssigning payn�en� of the rebate to the vendor does �ot exempt me Irom Backwater <br />Prevention Device Rebate Program requiremonts. <br />I aulhonze Ihe release of my rebate lo Ihe ventlor listed on the UaCk ot ihis torm pending <br />approval of Ihe compleled Backwater Prevention pevice rebale packet by the Ciry of Everett <br />J'� - ' L�A-1'�%a�� <br />Signalure of Property OWner <br />3 �'- /.5� <br />Date <br />