1326 E MARINE VIEW DR 2022-05-02

.. .. , i � �� Bac�Cwater Prevention Device � Rebate Program • For internal Use: Project Number: Vendor Payment iOption Form Please�Complete both sides of the form Property Owner Section j(please print): � M�il.�w I%��('s �Property Owner Name ; �3zc� � Maur►� View ,�rr�vc Eve�-l�F �A �SZC� ! Property Address � City tate Zip 2�7oµ 3�c� �-��. 5`Ur Fec�er��( �ra,�l GU�4 qfl0z3 •Alternate Mailing Address City State Zip Phone 2�6 25� 2d �-/ Email m��h �. �p{nC�S�!'�i ne� 1 I, the Property Owner, request to have the City of Everett Backwater Frcvention Device rebate check for the installatior� referenced at the Property Address be made payable to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable to the Vendor, I agree to the fo�lowing: i 1. i will not receive a Ba�kwater Prevention Device rebate check directly from the City of Everett. � 2. Assigning payment of th� Backwa.ter Prevention Device rebate to the Vendor does not exempt me from Backwater Prevention Device Rebate Program requirements. I authorize the release of my r,ebate to the Vendor listed on page two of this form pending approval oF the comp�eted Backwater Prevention Device rebate package by the City of Everett � "�� g __ �-- _��.� Signafure of Proporty'Owner- • GDate �. ' Page 1 of 2 Revised 91312014 �