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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Praject Number: _ __ _ (City to ProvideJ <br />Please complete both sides•of the form <br />Property Owner Section: <br />Property Owner Name: �p�P�'� �� <br />Installation Address: , ?JO� Z !'p�,�'sG� � <br />City: ��v.K.tiT" _ State: �� Zip: �8� � <br />Mailing Address (if diflerent): � / �q �(� � � i`yVC- � <br />City: � ,na,�, �_ State� �� Z�p: 98Z�6 <br />Email: _V' �Prrv �t44�YLl�ih�.{�1�iT Phone: ��i.�1 �� ��3.3� <br />Total Cost to Install Device (Irom contractorinvoice): 3 o�t3���g <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at ihe above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting lhe rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebate check directly (rom the City of Everetl. <br />2. Assigning paymenl of lhe rebate to lhe vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requiremenls. <br />! authorize the release of my rebate to the vendor listed ondhe back of this form pending <br />approval of the completed.Backwater Prevenlion Device rebate packel by the City of Everett <br />/I" ` <br />Signalure of Property Owner <br />/C� <br />/ � 'J`J <br />� <br />Date <br />