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Backwater Prevention Device Rebate Program <br /> Vendor Payment Optdon Form <br /> Project Numbec __ (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> i / <br /> j PropertyOwnerName� SUZCIYIV� M N��+�.I.Q,r <br /> i �L � <br /> I Installation Address a c�3�0� �1(J� <br /> City: ._�U�G�y�-T State: W� Zip: -t�Z�� _.__. <br /> Mailing Address (i(diNerent): __ <br /> 6ity: _._ State: __ Zip: <br /> Email: Phone: ( ) <br /> i <br /> Total Cost to Install pevice ((rom controctor invoice): $ ' <br /> � <br /> I, the property owner, requesl to have the City of Everetl Backwaler Prevention Dewce rebate check <br /> tor the installation of Ihe device at the above referenced property address be rnade payable to, and <br /> senl to, the vendor specl(ied on the back of this form. By requesting the rebate check be made <br /> payable to Ihe vendor, I agree to the following: <br /> 1. I ���111 not receive a rebate check directly from the Cily of Evprett <br /> 2. Assignmg payment oi the rebate to the vendor Aoes not exempt mr_ frnm Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebale to the vendor listed on the back of this form pending <br /> �pproval of the completed 8ack�vater Prevention Device rebate packet by the City of Everett <br /> �..r „-,,�� �n����— -�� �an►s <br /> Signature of Property Owner Date <br /> � — -. _ <br />