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Backwater Prevention Device �ebate Proc�ram <br />� Vendor Payment Option Form <br />Projecl Numbec (Cfry lo Provide) <br />Please complete both sides of the form <br />! Property Owner Section: <br />I <br />� PropeAy Ovmer Name; ! <br />I �h <br />Installatipp Address: <br />i . <br />J <br />( . Glly: <br />�� � <br />Stale: <br />_ �� <br />Mailing Address (il dillorent): � _ �/a �/�� <br />Cfly: State: Zp: h'n <br />Emgll: Phon€'('?S��-'�,�'�' � B� <br />_1 <br />Total Cost to Inetall Devica (/rom contracforinvoice)' $ -��i.�1�l.fd"r� ����,� <br />I, tne properiy owner, request to have the City oF Everelt Backwater Prevention Devico robete check <br />for the insWllation of the device at tlie above referenced property address be made payebte to, and <br />sent to, ihe ventlor specified on Ihe back of this fomt. By requesling the robate check be made <br />payable to the venAor, I agree to the fallowin9: <br />1. I wlll not recelve a rebate checK difeCUy Irom the City ot tverett. . <br />2. Assigning paymenl of �he rebate to lhe venaor does not exampt me from Etackwater <br />PrevenUon Device Rebate•Program requirements <br />I aulhorize Ihe release of my robate to the vendor Ilsted on tha back ol this form pending <br />approval of the c Ieted Backwater Preventton Devica robato pxket by the City of Evorett <br />J j <br />' - �`T'/%,Y"/ <br />-� .��• .- - - �. <br />Signature ol Properly Owner <br />Oate <br />