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i <br /> � <br /> Backwater Prevention 7evice Rebate P�rogram <br /> Ve�ndor Payment Option Fcrin I <br /> Project Number. (Ciry to P�ovide) I <br /> { <br /> Please complete both sides of the form � <br /> Property Owner Section: , <br /> Property Owner Name: (_�[Ll7►�f -CJ"a1 g G� ✓Gf � <br /> InstallationAddress: 2,�1� `7'nu-�� �� <br /> City:-�V2t-t�� State: W� Zip: �� �� i <br /> Mailing Address(if difTerent): � <br /> City: State: Zip: <br /> EmaiL LQ . /1�9Q-rGL��./n/n�.L�t'h Phone: �i�p � g�' ` 0/ 9 �7 <br /> � �o <br /> Total Cost to Install Device(ham conbacforinvoice):$ '.Z�by• � <br /> I, the property owner, request to have ihe City of Everett Backwater Prevention Device rebate check <br /> for the installaUon of the devioe at the above i�eferenced property address be made payable to, and <br /> sent to,fhe vendor specified on the 6ack of this fortn. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: � <br /> 1. 1 will not receive a rebate check diredly from lhe City of Everett. ' <br /> 2. Assigning payment of the rehate to the vendor does not exempt me from Backwaler � <br /> Prevention Device Rebete Program requirements. <br /> 1 authorize the release of my rebate to ihe vendor listed on ihe 6ack of this fonn pending I <br /> approval of ihe eompleted Backwater Prevention Device rebate packet by Ihe City oF Fverett <br /> , .� /d�'�'S— <br /> Signature of Pro Owner Date <br /> � <br />