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' Backwater Prevention Device Rebate Progr�m <br />r Vendor Payment Option Form <br />Project Number: <br />(City to Provide) <br />Please compiete both sides of the form <br />Properiy Owner Section: <br />PropFrty Owner Name: ����� % �S � <br />Installalion Address Z/ 2 Z %�GQ���� ��_ <br />City�� ��25lI State: ��� -----Zip: �7 d �U� <br />_ i. ' <br />hlailing Address (il diHerent): _ "'" � � ' <br />City:� State: s' _—Zip� <br />Email' _ - — --- ---- — Phone: ( ) --- -- <br />Total Cost lo Install Device (from confractorinvoir.e): 5 <br />I, the properiy owner, request to have, the CiJy of Everetl Back�•�ater Prevention DeJice rebale check <br />(or the installation of the device at the_above referenced property address be made,payable to, and <br />sent to, ihe vendor specified on ihe back of this form. By requesting the rebate check be made <br />payable to lhe vendor, I agree to the following: <br />,. . : �:: <br />t. I will not receive a rebate check directly trom.the City of,Everett <br />� L. . <br />2. Assigning payment of the rebate to the vendor does nol exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my reba!e to the vendor listed on thc bac� of this form pending <br />approval of the cc�ipleted Backwater Prevention Device rebate packet by the City o( Everett <br />��Z� /��— <br />Signature of Property ON�ner �ate <br />