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�` <br /> Backwater Prevention D�vice Rebate Pr; � EaypJ���� <br /> Vendor Payment Option Form ���� D <br /> n ,L �t� � � �0�4 D <br /> Project Number: T �"I I I - O U y (City to Provide) <br /> (p�m;t�) <br /> PUI3LIC V✓ORKS <br /> Please complete both sides of the form <br /> Property Owner Section: , <br /> PropertyOwner'Name: �+'�-� ,' `���"� <br /> Installation Address: ��5 l-6M,�w-�� �'e" <br /> City: �1�2f� State: �� Zip: ���1 - � � � <br /> Mailing Address (if dil(erenf): — <br /> Cily: -- State: � Zip: <br /> Email: Yr1ac G ru.cltP,� �nfi'er (:uvr1 Phone: ( /3f�L 2-S���_ I <br /> ,(O/� ! <br /> Total Cosl to Install Device ((rom confracforinvoice)� $�T D-I. 7� <br /> I, the property owner, requesl lo have ihe Cily of Everetl Backwater Prevention Device rebate check <br /> for the installation of lhe device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable lo lhe vendor, I agree lo ihe following: <br /> 1. I will not recei've a rebate check directly from lhe Ciry of Everetl. <br /> 2. Assiyning paymenl of the rebate lo the vendor does not exempt me from Backwater <br /> preven�ion Device Rebate Pragram requirements <br /> I authorizc lhe retease of my rebate to the vendor listed on the back of lhis form pending <br /> approval of lhe completed Dackwater Prevenlion Device rebale packet by lhe City of Everett <br /> ��"'u""'Ul����/`,WiG� _ ll /�� lT <br /> Signalure of Properry Owner Date <br />