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�N�� Backwaier Pr��verrtion Device Rebate Pr•ogram <br />E,-� VEncor Payment Option Form <br />Project tJumber: _ _ _ _._ _____. (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />� <br />Property Ovmer Name: �Q,/'/ � _�l�S' �S � <br />Inslallalion Addms:,: � 2. �_ j �o% � <br />c�ry: ^ � r� 7�- staie: �i//�—._ ziP: 9��Z O/ <br />Mailing Address (i( diflerent): <br />City: _ Stale: <br />Email: <br />Phone.,4220� 5��5 C74��Z�_ <br />Total Cost to Install Device ((rom contractor invoice): S_ 2�5� r� <br />I, the propery owner, requesl to have lhe City of Everelt Backwater Prevenlion Qevice rebate check <br />(or the ins�allalion of Ihe device at the above referenced property address be made payable to, and <br />senl to, the vendor specified on the back of lhis (orm. By reyuesting ihe rebate check be made <br />payable to the vendor, I agree to the followiny: <br />1. I will nol receive a rebale check direclly from the City of Everetl. <br />2. Assigning payment o( lhe rebale lo thc vendor does not exempt me from Backwater <br />Prevenlion Device Rebate Program requiremenis. <br />�I authorize the release oi my rebale lo the vendor lisled on Ihe back o1 this �orrn pendiny <br />approval oi the completed Backviater Prevention Device rebate packel by the City o( Everett <br />� /' � <br />/ i�/ ^ w if.fi/ �/ � ' /( A-�/�f�'j✓ ��j�� ���� - <br />Signature of Property Owner Da�e <br />