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Backwater Prevantion Device Rebdte Program <br />� �r Vendor P��yment Option Form <br />Project Numbei __ __ (City ro ProvideJ <br />Please complete both sides of the form <br />Property aHmer Section: <br />Property O�vner Name: �C/{a� =R v�n/� _ <br />Inslallation Address: �j 3 3? h`D <br />City: �✓C-72 ��% State: _ u/� zip: 9 f' Z o� <br />Mailing Address (if diHerent)� _ l�� O•��C � y�� <br />City: �C�-E;E%sfi _ Slate. �' %� - Zip; � � 2 O � <br />Email: �SZ �Cu+uC�� ; n/�'-f Phone: (YZf ¢ � 3' �) `i3 � <br />,i <br />Total Cost to Install Device ((rom con(rector invoiceJ: S �� L S <br />I, the property owner, request to have the City of Everelt Backwater Prevention Device rebate check <br />for lhe installation of the device al the above referenced property address be made payable to, and <br />sent to, Ihe vendor specdied or the back of this form. By requesting �he rebate check be made <br />payable to the v2ndor, I agree lo the iollowing: <br />1. I will nol receive a rebale cLeck diredly from lhe City of Everett <br />2. Assigning paymenl of lhe rebate to the vendor does not exempt me from Backwater <br />P�evenlion Device Rebate Program requiremenls. <br />I aulhorize lhe reiease of my rebate to the vendor listed on lhe bacK of this form penoing <br />approval oi lhe compleled Backwaler Prevenlion Device rebate packet by the Cify of Everett <br />��'//�� �_,�-r-Y�r�- <br />Signature of Property Owner <br />� /0 20/ � <br />Dale <br />