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Backwater Prevention Device Reba4e Program <br />t,. Vendor Payment Option Form <br />Pro�ect Number: __ __ __ (City to Provide) <br />Please complete both side� of the•form <br />Property Owner Section: <br />Property Owner Name _�j� �(�y�i-t�/r `�Vt,c:'rrir � _ <br />� <br />Installalion Address: ��i_Q��" }_Pr'�P�^'{ �'� - <br />� 1� �y� <br />�'tY _l:.i��L�_� __ Staie: _�L� ! I _ Zip: �� � <br />�vlailing Address (il diNerent) <br />Ciry: —_ <br />Email' <br />State: <br />_ Phone ( <br />Totai Cost to Install Device (lrom contracfor invoice): 5�'7� �% <br />I, the property owner, request lo have the Cdy o( Everelt Backwaler P�evenlion Device rebate check <br />(or the installation of the device at the above referenced properly address be made payable to, and <br />sent to, the vendor specihed on lhe back of lhis form. By requesliny the rebale check be made <br />payable to the vendor, I agree to the following: <br />1. I��ill not recerve a rebale check direcUy from the City of Everetl. <br />2. Assiyning payment of the rebate to lhe vendor does nol exempt me frorn Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate tn the vendor listed on the back of this (orm pending <br />approval of Ihe completed Backwater Prevention Device rebale packet by the City oi [verelt <br />� �L ���/.X /1-__ <br />(JS gnalure of P'r perly Owner <br />n2 ,' .S� <br />Date <br />