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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: _ G I e Y\ I—T � �D.C.V�OI'� --� <br /> Installation Address: _���3__G U11 V �N�- <br /> City: �Vel�e 1 1 State: �/ _�_Zip: �SG-�� <br /> Mailing Address(il dilferent): _ <br /> Gily: State: Zip: <br /> emai�. Gi�'1L0.1�Y'PY1L��C011'1CC•tS��n� Phone: (2C� �� ���-3 <br /> Totai Cost to Install Device (from confractor invoice)� $ c� i�J u lol 1 <br /> I, the propetty owner, request to have lhe City oi Everett Backwater Prevention Device rebale check <br /> for the inslallalion oF the device at lhe above referenced property address be made payable to, and <br /> sent to, the vendor specified on Ihe back of lhis form. By requesting the 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 Everett. <br /> 2. Assigning payment o(the rebate to the vendor does nol exempt me from Back�vater <br /> Prevenlion Device Rebate Prograrn requirements. <br /> I authorize !he release of my rebate lo lhe vendor listed on lhe back of this form per.ding <br /> approval oi Ihe completed Backwater Prevention Device rebale packet by Ihe City oF EvereN <br /> ,�ti`��,2c��'�,,�a.,_LQ�u�I 5 � I I l5 <br /> SignaWre of Property Owner «e«�� ` 1' `�a��'`'�n Dale <br />