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i <br /> i <br /> Backwater Prevention Device Rebate Program i <br /> Vendor Payment Option Form � <br /> � <br /> Project Number:__ (City l�Provrde) � <br /> � <br /> i <br /> Please complete both sides of the form <br /> l <br /> i <br /> Property Owner Section: � <br /> i <br /> — - ---- i <br /> i <br /> Property Ov✓ner Name: � u� i E �� -�( _ � <br /> � <br /> InstallationAddress: /L. '1� Lom.�t���. �v� ! <br /> � <br /> City: ✓c % 'i State: CJ�.- Zip:_.y�',�UI _ . ! <br /> Mailing Address (il diHerent): ___ i <br /> Cily: _ State: Zip: � <br /> i <br /> Email: Phone: �j;� � -' (a �c i <br /> Total Cost to Install Device ((rom cont�actorinvnice): ��,�,_�� __ [ <br /> I --._ _. -- ---- <br /> I, the property owner, request to have the Ci1y of Everett Backwater Prevention Device rebate check • <br /> (or lhe inslallalion of the davice at ihe above referenced property address be made payable to, and � <br /> �ent to, lhe vendor specified on lhe back of lhis form. By requesting the rebate check be made <br /> payable to the vendor, I agree to ihe foilowing� ' <br /> i <br /> 1. I wili not recelve a rebate check directly from the City of[veretL i � <br /> 2. Assigning payment of lhe rebate to the vendor does not exempt me irom Backwater <br /> Prevention Device Rebate Program requirements. i <br /> — -- — -- -- i <br /> I aulhorize Ihe release of my rebale to the vendor listed on the bar,k of this form pending <br /> appwval of the completed Backwatei Prevenlion Device rebate packet by Ute City o( Everett <br /> i <br /> ; <br /> � <br /> � <br /> ���.�������. �i� -�,,� ' <br /> � � ; <br /> 6ignalure of Property Owner Date <br /> -- — — -- <br /> ; <br /> f <br /> ) <br /> i <br /> 1 <br />