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Backwater Prevention Device Rebate Program <br /> Vendor Pa� ment Option Form <br /> Pro�ect Numher. __ _ (City fo Provide) <br /> Please complete bo4h �ides of the form <br /> Property Owner Section: <br /> - ---- — — i <br /> Property Owner Name: C-1�„lo,,. 1 • S �.01��.�6„� I <br /> � <br /> � Installation Address: 1 y 3`{ (�r�w 1�v� <br /> City: G�e�tJ�'1 State' I,✓A 2ip: 9�'7–J � <br /> �.4ailing Address (if difleren!):_ ___ <br /> City: State: Zip: <br /> � <br /> Email: Phone. ( ) i <br /> Total Cost to Install Device(from cwifrac(or invoice): $ 3,'LSI`� �- fr* <br /> L — ---- — <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the instailalion of the device at the above reterenced property address be made payable .o,and <br /> senl to, the vendor specified on ihe back of this form. By requesling the rebale check be made <br /> payable to lhe vendor, I agree to the fo;lowing: <br /> 1 I will not receive a rebale check direcdy from the City of EvereU. <br /> 2 Assigning payment of Ihe rebate to the vendor does not exempl me from Back�valer <br /> Prevention Device Rebale Program requiremenic. <br /> � I authorize lhe release of my rebale lo the vendor lisled on lhe back of this (orm pending 1 <br /> � approval of Ihe compleled Backwaler Prevenlion Device rebate packet by the Cily o( Everetl <br /> � <br /> �_j�,��_ ����1-J/S i <br /> � Signature of Property Owner — Date � <br />