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�_� <br />Backwatar Prevention Device Rebate Program <br />F��r Vendor Payment Option Form <br />Project Number _ _, _ __ _ _ __ _ (City to Provide) <br />„.�Y . <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Ov+ner Name��� S ���,�y� 7✓-E«-� _ __ <br />!^`�',/ -- <br />Inslallalion Address: _ ��� ��� ' � ��UQ V i1ZkJ� � �`"e <br />City.�U�l�__State: �'�' Z�p: / �y�� <br />A4ailing Address (il dillerentJ: � .i�_�a � � 6�_� __ <br />�_ —_._�- v <br />Cily �LIlR-� Stale' uk+- _ Zip � O zo �-- -.— <br />Email /F�� �9�,�/,fi��.�-�i4/�S � l..D� Phone (��if 2� 7�'�D� <br />Total Cost to Install Device (�rom r,onfractor invoir.e) 5�p %o �' �— _ <br />I, the property owner, requesl lo have Ihe City of Everett Backwater Prevention Device rebate check <br />tor the installation of the device at tne above re(erenced property address be made payable to, and <br />sent to, the vendor specified on the back of lhis form. By requestieg lhe rebale check be made <br />payable lo the vendor, I agree to the follo�•�ing: <br />1 I�vill not receive a rebate che^.k directly from the City of L-vCrett. <br />2. Assigning payment o( lhe rebc�e to lhe vendor does nnt e.•empt me from Bar.kwater <br />Preventinn Device Reha;� Frogram requirements. <br />- _ -- -- --- --------� <br />I authorire the release nf my rebate to the vendor listed on the back o( �hls form pending <br />approval of the completed Backwater Prevenlion Device rebate packel by the City of Everett <br />, �,.../�i T�Z- Zf� l.s <br />i ature of Propert Owner Date <br />