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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � � <br /> Property Owner Name: �Y'!i � 4 / u-f����� <br /> � �J � <br /> � Installation Address: a� � / 2�� ✓� I <br /> II i <br /> Cily: ✓�rlt' ; State ����/�f Zio:� �� <br /> Mailing Address (il diBerent):_ <br /> City: __ State: _Zip: <br /> Email _ C p�tYl�rrS O �'1%h tJS r��n , C'h7�. Pho�e: ly'j�•} .��9`"9�'� y �' <br /> � '�J> U 7 �� <br /> Total Cost to Install Device (lrom contracbr invoice): 5 6— ��„ <br /> �_ __ <br /> I, the property owner, request to have Ihe City of Everetl Backwater Prevenlion Device rebale check <br /> (or lhe installation of the device al Ihe above re(erenced property address be made payable to, and <br /> sent lo, Ihe verdor specdied on the back of this form. By requesling the rebal�cherk be made <br /> payable to the vendor, I agree to the following: <br /> 1. I �vill nol receive a rebate check direclly (rom the City of Everett <br /> 2. Assigning payment o(the rebate to the vendor does not exempl me from Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> I aidhorize Ihe release of my rebate lo lhe vendor lisled on the back of Uiis fomi pending <br /> approval ot the compleled Backwater Prevention Device rebate packel by Ihe Cily of Everett <br /> t%� ��i.�/ ' � Dj �3 i� <br /> Signature of Properly�Owner Dale <br />