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/ Backwater Prevention D�vice Rebate Program <br />� Vendor Payment Option Form <br />Project Number. (Ci(y fo Provide) <br />Please complete both sides of the form <br />Praperty Owner Section: <br />Property Owner Name: �–FJ�;CP�Cl� ��{%Z,(,���"F� <br />Installation Address: Z$� (��na (C <br />� — � �. <br />City: C/V'�l�'i'i� _ Sta�e: ��_ Zip: �$ zQ� <br />Mailing Address (if dillerent): <br />City: <br />S;ate: <br />Email: �L16Pr�;X�1C( {��Fu4�YY�iQ,�GJfil Phone: (�H�) '7hSS' "7,G,3� <br />7otal Cost to Install Device (Irom con(ractorinvoice): $ <br />I, the property ov,-ner, request to have Ihe City of Everelt Backwater Prevention Device rebate check <br />tor the inslallation of the device at the above referenced pr�perty address be made payable to, and <br />sent lo, the vendor specified on Ihe back of Ihis form. By requesting the rebate checl: be made <br />payable lo lhe vendor, I agrec to the followiny: <br />1. f will nol rec�ive a rebale check diieclly irom the City o( Everelt. <br />2. Assigning paymenl of lhe rebatr. lo the vendor does not exempt.me (rom Backwater <br />Prevenlion Device Rebale Pioyram requiremenls. <br />I aulhorize the rcleasc of r1ry rebale to the vendor listed on Ihc back o( lhis form pending <br />approval o( the cumpleled Bsck::�.aler Prevenlion Devir,e rebate packel by Ihe City of Everett <br />�'i " / �� -- — <br />Signature of F, �rty Owner <br />�1�� �� - <br />Date <br />