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Backwater Prevention D�vice Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete bath sides of the form <br /> Property Owner Section: <br /> Property Owner Name: �U n � ��nC{�l We-��i --__ <br /> InstallationAddress: c��.OG �-1.�m'UC' rGl __ ___ <br /> City: �/U�Y�'t� State: w rr _Zip� ��2O � <br /> Mailing Address(if diiferenO: <br /> Cily: State: Zip: _ <br /> EmaiC ���LII ��2(`"" C0I���1 Pnone: (d�%jo252.—�1/c��/.'� <br /> Total Cost to Instail Device (from contractor invoice): 5 <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation o(the device al lhe above referenced property address be made payable to, and <br /> sent to, the vendor specitied on the back of this form. By requesiing the rebale check be made <br /> payabie to the vendor, I agree to the following: <br /> 1. I will not receivQ a rebate check direcUy Irom lhe City of Everelt. <br /> 2. Assigning payment of the rebate lo the vendor does not exempt me from Backwaler <br /> Prevenlion Device Rebate Program requiremenls. <br /> I auU�onze lhe release o( my rebate�o the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevenlion Device rebate packel by ihe Cily of Everett <br /> Signature o(Property Owner Date <br /> � <br /> � <br />