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� Backwater Prevention Device Rebate F'rogram <br /> E„ Vendor Payment Option Form <br /> Projact Number __ __ (City to Pruvide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � -- - - -- — — -- - � <br /> Property Oemer Namc _�^/�_ � � s �''/i✓Y'1'� - <br /> Instalfation Address�. _ �0_�� �P�� _ I� <br /> City: ���'f��� State: ��Zip:����� � - <br /> Mailing Address(if dil(erent): <br /> Cily: _ State: _7_ip:_----_- - --. - � <br /> [mail: � V���'���l%'r!f'cJ_ cs. f.Oi�,LG'r' Phone: �)_2Jc�(� _ I <br /> � Tatal Cost lo tnstall Device (from contractorinvorce): 5 _���_���� _.— I <br /> �J <br /> I, the p;operty ovmer, request to have the City of Fverett Backvrilr�r Preven!ion Device rebale check <br /> for the inslallalion of lhe devi ce at the above referenced propery address be rnade payable to. and <br /> c��nt to, the vendor specihed on the t�ack of this (orm. By requesting the rebale chech bo mr�dn <br /> payablc to ihe vendor, I a�ree to Oie following: <br /> 1. I will nol receive a rebale check directiy(rom �he Cily nf Everett. <br /> 2 Assiyning paymenl of lhe rebate to the vendor does not exempt me from Back�:a�ei <br /> Prevenhon Device Rehate Program �equiremenls. <br /> � I authoii7c Ihe release of my mhate �o lhe vendor listed on thr. hack of Ihis (orm pending I <br /> approval of lhe completed Back�vater P�evenlion Device rebate packe! by Ihe City of Everelt ; <br /> I �,c�_� �v . �.Gui�°✓ ----- l r ,8� �� I� I <br /> � S�alure of Property Owner Dale <br /> - - _ _ _- - - � <br />