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Backwater Prevention Uevice Rebate Program <br /> Vendor Payment Option Farm <br /> Project Numbec (Cily to Provide) <br /> Ple;ase complete both sides of the forrri <br /> Property Owner Section: <br /> Property Owner �3me: �q��/ �� b/.Lu $ o k <br /> inslallation Address: /y.�� �b an �OQ✓�r� __ <br /> I <br /> ' City: Fva ra � State: �a _zip: g$.ZO 1 <br /> Mailing Address (if diHerent): O 1 7t'a�a ,/.��1 _ — <br /> � city: IVI4r�evi�[,2 state: l�/G1 ZiP:��'17b --- I <br /> Email: I4'�'/'YL� ��txp�oY l�-Pv`�--•Gvu� Phone' (��3�5� /S��'i <br /> Total Cost to Install Device (Gom contractor invoice): 3 __ <br /> I, Ihe prope iy o�vner, request to have the Cily of Everelt Backwater Prevenlion Device rebate check <br /> for the installation of the device at the above re(erenced property address be made payable to, and <br /> sent to, the vendor specified on the back of this form. f3y requesting the rebate check be made <br /> payable lo the vendor, I agrce to the following. <br /> 1. I will not receive a rebale check direcdy from the Cify of Everett <br /> 7. Assigning payment of the rebate to tLe vendor does not exempt rne from Backwater <br /> Prevenlion Device Rebate Program requirem�nts <br /> I aulhorize lhe release o(my rebale to the vendor listed on the back o(lhis form pending <br /> approval of ihe cornpleted Backwater?revention Device rebale packet by the City of Evereti <br /> � � 2 � ��/ � <br /> �� <br /> Signature of Property O ner Date <br />