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4 Backwater Prevention Device Rebate Program <br />aw Vendor Payment Option Form <br />Project Number _ _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />W VIA q.'l <br />Property Owner Name: Pherfean Granbery <br />Installation Address 3414 Oakes Ave <br />City: Everett State WA Zip.98201 <br />Mailing Address (d dlNerent): <br />City: <br />State: Zip: <br />Email: nancyboyerl3@hotmail.com Phone: (425) 765-6204 <br />Total Cost to Install Device (from contractor invoice) $ 2,500.68 _ <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referenced properly address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor. I agree to the following: <br />t. 1 will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwaler <br />Prevemon Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />Signatwe of Property Owner <br />j.-zC- -rs- <br />Date <br />