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z Backwater Prevention D��ice Rebaie Program <br />Vend�r Payment nption Form <br />Pro:ect Number: (City to Piovrde) <br />Please corr��iete both sides of the for�r; <br />Property Owner ;iection: <br />Property Owner Na�ne: <br />Installation Address: <br />ciry: �{= v2T stato: <br />Mailing Address (il di/ferant): I LI I D I �'-' "� �% v�u�! <br />City: �1�-2V-�C�f Stale: V✓� ,� Zip: / � �� _ <br />Email:,/7Yn�LGb�r�—Q�.t� �'__ /R'a^'� ' Phone: ( ) <br />1� �j U <br />Totai Cost to Install Device (from confracfor inwice): $ �`t �• <br />I, the property owner, requost to have the City of Everett Backwater Prevertfion Device rebate check <br />fcr the instelletion of the device at the abovs referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the.vendor, I egrecr to the following: , <br />1. I will not receive a rebate check directly from the City of Everett <br />2. Assigning payment of the rebale lo the vendor does not exempt me from i3ackwaler <br />Prevention Device Rebate Progrem requiremenL�. <br />I authorize the release of my rebate to the vendor listed on the back of this fortn pending <br />approval of lhe completed Backwater Prevention Oevice rebate packet by Ihe Ciry of Everett <br />9 �J� s— <br />Date <br />