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Backwater Prevention Device Rebate Program <br />Vendor Pr�yrnent �ption Form <br />Projecl Number: _ (City to Frovide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: I'� 1 r I,a � , �a v°� �- <br />/� i p�� <br />InslallationAddress: �-s0`1 13��`rl� �N� <br />c�iY: S,�rr � sta��: V�� z��: `l� �a i -- <br />Mailing Address (if diffe�ent): <br />City: 5cti--� �tate: <br />Email: <br />Phane: ( <br />Total Cost to Install Device (frorn contractor invoice): S�� �_� � <br />I, ihe properly owner, request to have the Cily of Everett Backwater Prevention Oevice rebate check <br />for Ihe installalion of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requosling Ihe rebale check 6e made <br />payable to the vendor, I agree to ihe toilcwing: <br />1. I will nol rnceive a rebale check direcliy from lhe City of Everell. <br />2. Assigning payment of the rebate to the vendor does not exempl me from Backwater <br />Prevention Device Rebale Program requirements. <br />I authorize Ihe release oF my rebale lo Ihe vcndor listed on Ihe bar.k of this form pending <br />approval of the completed 8ackwaier PreveNion Devir.e rebate packel by the City of [verefl <br />/ ' �/, <br />�2' �( -I`( - ►S <br />Signalure of Prope y Owner Dale <br />