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Backwater Prevention Device Rebate Program <br /> � Vendor Payment Option Form <br /> Project Numbec (Clty fo ProvideJ <br /> Please complete both sidas of the form <br /> Property Owner Section: <br /> �� �jI,� J n1 An ersr>� <br /> � Prope' rty O�vner Name: I�'I�M�S T L2�i� !-{N�¢LYo✓ -- <br /> I u- <br /> �I InstallationAddress: t��Z If/�� �v� <br /> � t5 e Fe � 8 �"�� <br /> City:_ V � State: �n//} Zip: <br /> tvlailing Address(if dillerent): <br /> City: _ Stale: ZIp:_ _ <br /> j Email: ��n1�e50r/� �M��I , GnM Phone: (4ts) 3't3 � dl�ll <br /> ITotal Cost to Instali Device (/rom contractor invoiceJ 5 �,SCG/� = I <br /> L� —� <br /> I, the property owner, request to have the Cify of Everett Backwater Prevention Uevice rebate check <br /> for lhe inslallation of the device al lhe above referencad property address be made payable to, and , <br /> sent to, lhe vendor speci6ed on the oack of lhis form. By requesting the rebate check be made ' <br /> payahle lo lhe vendor, I agree to the (ollo���ing: <br /> 1. I will not receive a retiate check directly from lhe City of Everell. <br /> 2. Assiyniny payment o(lhe rebale lo lhe vendor does not exempt me from 8ack�vater <br /> Prevenlion Device Rebale Program requirements. <br /> I aut iorize lhe release of my rehale to lhe vendor lisled on the back of lhis form pen�ing <br /> approval ot lhe completed Backwaler Prevenlion Device reba�e packet by lhe City ol Everetl <br /> -���_\ ������ �2 — d'—2o(S <br /> I <br /> Signature of Property Owner Dale <br /> 4 <br />