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Backwater Prevention Device Rebate Program <br />Ev Vendor Payment Option Form <br />Prajec4 Numbec ___ __J (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />� Properly Otvner Name: =��`� �i �I � ✓1C� <br />, InstallationAddress:��_�a �`o��t�i�P(/i✓P _ <br />City: _�_U• I State: Ll�r Zip �'( �y' �d ( <br />hiailing Address (ildilferentl� <br />Cily: State: Zip: <br />[mail: <br />Phone: ('i-j5)�0-'4(��� <br />Total Cost to Insta�l Device (!rom contracfor im�oice): S_ Z S� � <br />I, ,he property o�vner, request to have the City of Everett Backwater Prevention Device rebate check <br />for lhe installation of lhe device at the above referenced property addre.ss be made payable lo, and <br />senl to, the vendor specified on the back of lhis `orm. By requesting the rebate check be made <br />payable to the vendor, I ayree to Ihe iollowing: <br />1 I will not receive a rebate check directty (rom the City of Everett. <br />2. Assigning payment of lhe rebale to the vendor docs not exempt me from Backwaler <br />Prevention Uevice Rebale Program requiremenls. <br />i I auQiorizc lhe release of my rebate to the vendor listed on the back of this form pending <br />� approval oi the compleled Backwater Prevention Device rebale packet by lhe City of Everetl <br />i <br />��' '��1 � 3-18-�5 <br />� Signatur f Property Owmer Date <br />