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Backwater Prevent�on Device Rebate Program <br />� Vendor Payrrient Option Form <br />Project Numbec _ (City to Piov�de) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: ��l (r ��J Fti �' `Cl(�ll L'• L. l�, f <br />Installation Address: - 1� � �_� '�V'e-� � <br />City: ,L�� State: �____ Zip: � 77 � I <br />��, Pdailing Address (i(dillerenf): <br />� City: State: Zip <br />� Email: Phone:(4�) ��-3�j0� <br />� Total Cost to inslall Device (/rom confraclarinvoice): $ ���1 '� � <br />I, Ihe property owner, requesl lo have Ihe City of Everelt Backwater Prevention Devicr. reba�e check <br />Wr the installation of Ihe device at the above relerenced property address be made payable lo, and <br />sent to, Ihe vendor specilied on Ihe bar.k o( Ihis form. By requesling lhe rebale check be made <br />payable tn the vendnr, I agree �o lhe following�. <br />1. I will nol receive a rebate chr,ck direr.tly from lhe City ol [vr,relt. <br />2. �sslgning paymenl ol lhr rebale to the vr,ndor doos not exr.mpt mr, frnm Backwater <br />Prevention Device Rebate Pregram reyuirements. <br />. I authnrize the rr.lcasc of my rebate lo U�e vendor listed on the bar,k of this fortn pendinc� <br />�, appruval ot Ihe compleled Backwaler Prevenlion Device rebale packet by ihe City of �verett <br />! �cl� � g,�,-� � a ' <br />� <br />� Signatu:e of Property Owner Date <br />