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i _ <br /> II <br /> , Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> ' Projer.t Numbec (Cil y to Provide) � <br /> IPlease complete both sides of the form <br /> �' Property Owner Section: I <br /> � <br /> � Property Owner Name:�r IL/i� r n � S i <br /> Ins ta l la tion A d dress: � �?1���_�t. I�r r d • <br /> � -}-�- State:��_Zi �'i � 7 O � + <br /> Cily' Sitrcn� R <br /> 1 <br /> Mailing Address (ilditlerent): � <br /> � <br /> i <br /> City: State: Zin: <br /> I Email: S�� (r G ZQ�3� a �� _Phone: (y�)�� 3 oZ— n �-l�T� <br /> 3o ITotal Cost to Install Device ((rom contracfor rnvoice): S����� <br /> i <br /> 1 <br /> I, the p;operty owner, request to have ihe City of Everett 8ack�vater Preve�tion Device rebate check � <br /> for the installation ol the device at the above referenced property address be made payable to, and <br /> sent to,the vendor speci(ied on the back of this form. By requesting the rebate check be made <br /> oayahle to the vendor, I agree to Ihe following: <br /> 1. I will not receive a rebate check directly from the Cily of Everett. <br /> 2. Assiyning paymenl o(the rebale to the vendor does nol exempt me from Backwaler <br /> Prevenlion Devi�e F.ebale Program requiremenls. <br /> I authorize the release of my rebate to the vendor listed on lhe back of this form pending <br /> approval o(�he completed Backwater Prevenlion Device reba�e packet by the City of Everett <br /> � <br /> D p (�� � / �' <br /> {l\OC1'� �/ltin.Y�'`l �� <br /> �' <br /> Signature o(Properly Owner Date <br /> i <br /> � <br />