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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Pro�ecl Numbec (Cdy fo Provide) <br /> Piease complete both sides of the form <br /> Property Owner Section: <br /> I <br /> i Propery Owner Name: �!f M_4,,�H y <br /> I Inslallalion Address: 3GG�o lreL�N�Y t� <br /> I Cily:�V ov�J.t _S�ate. w�' Zip: �tLo/ <br /> ; fvtailing Address (iI diNerent): Z��� we+.-�ie A�P <br /> IC�ty: L'Veif��' Stale: n.�� Zip: ��/ <br /> � I <br /> Email: Phone: (yt3) Z.SZ � ��L 7.Z <br /> Total Cost tu Install Devfce(from contracfor invoice): 5 2- S GO. -� <br /> � _ <br /> I, the property owner, request to have the City of Everett Back�vater Prevention Device rebate check <br /> for lhe installation of the device at the above referenced property address be made payable to, and <br /> sn��� lo, the vendor speci(ied on the back of this(orm. By reyuesfing the rebate check be made <br /> payable lo the vendor, I agree lo the following: . <br /> 1. I wtll not receivc a rebale check direclly from Ihe City of Everett <br /> 2. Assignmg payment of the rebate to the vendor does not exernpl me from 6ackwater <br /> Prevention Device Rebale Program requirements. <br /> ', I authorize the releosc of my rebate lo lhe vendor listed on Ihe back of this form pending <br /> �� approval of lhe completed Backwater Prevention Device rebate packet by the City of Everett <br /> I <br /> � . <br /> � <br /> � <br /> ' -��,-,��., � ���K-��,f'� cc_;��< � _ �/��/S_ <br /> I� - , , <br /> Signalure of Praperty Owner U Date <br /> ' – —-- ---------- -- <br />