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.7 <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Numher ___ _ ���ry�o Piovide) <br /> ?iease con�pieie baiii sicies o'r tiie form <br /> Property Owner Section: <br /> ------- — --------- --1 <br /> Property0wnerName ��Mbe,��ee _��e�5en <br /> InstallalionAddress I21� �Tf�--- --- <br /> Ciry: 'EYQ(2i"f State:lil� A __Z�p;gg Zl�I I <br /> MailingAddress(i(di/(eren7J `d( �� ✓�� '��, I <br /> City .N1-�_y�' �LD Yl __ State: Lt� J} _Zip:�.S t=1�_ I <br /> Email ��� �� 0.�LDD. CBCVI Phone: (�L� �',�oZ I <br /> Total Cosl to Install Cevice (lrom confractor invoice): S --- — _— I <br /> � <br /> I, lhe property owner, requesl lo have the City ol Everett Backwater Pravention Device rebate check <br /> for lhe in,tallation ol Ihe device at Ihe above referenced property address be made payable to, and <br /> senl lo, the vendor specified on the back cl Ihis form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the followin9: <br /> 1. I will nol recelve a rebate ct:eck direcUy trom the Cdy of Everelt <br /> l. Assigning payment of the rebale to the vendor does nol exernpl me from Backwater <br /> Preventlon Device Rebale Program requirements. <br /> I aulhorize Ihe release o(my rebale lo the vendor Ilsted on Ihe back of Ihis form pendlnc� I <br /> approval o(Ihe completed B2ckv�ater Prevenlion Devic� rebale packet hy fhe Clly of Everelt I <br /> I i <br /> i <br /> � ������-_--- =-�I�--«-- � <br /> Signalure of Property Owner Date <br /> — -- — — -__ --- - ------- - --- --- <br />