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.;� . . <br /> Backwater PrevenQion Device Rebate Program <br /> : r Vendor Payment Option Form <br /> Projecl Number. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ���. � ��'�"� <br /> InstallationAddress: /5�3 � L-vr, J�--c.� /�—��'—. <br /> Ciry: !�t.�2-Yt State: W� Zip:_ (�� � <br /> Mailing Address (i(diHerent): q �� /"`!..-f i� �/'- � � <br /> city: �c�n�lS v, �� State: 1�.��zip� �6 2�" � <br /> Email: `�-� i z.��"J s=�� l-L�^-� Phone: (�f�Z 3 I -�� �S� <br /> Tolal Cost to Install Device (lrom contractor invoiceJ: 5��C�,� � �__ __ <br /> I, the property owner, request to have lhe City of Everett Backwater Prevenlion Device rebale check <br /> Tor the installation of lhe device at lhe above re(erenced property address be made payable lo, and <br /> sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I ayree to the (ollowing: <br /> 1. I will not receive a rebate check direcUy from the City of Everett. <br /> 2. Assigning payment of the rebate to lhe vendor does not exempt me from Back�vater <br /> Prevention Device Rebale Program requirements. <br /> I aidhorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of lhe compteted t3ackwater Prevention Device rebate packet by the City of Everett <br /> . !J <br /> .'> - 3c� - /S� <br /> ignature of Property Owner Date <br />