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i <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> i <br /> � Project Number. _ (City to Prvvidr,) <br /> I <br /> i <br /> I <br /> iPiease complete both sides of the form <br /> j Praperty Owner Section: <br /> Property O�vner Name: lA/ r�j R�nf J�n/A+� I <br /> Instal!ationAddress: �J�i/ Voc�lo �ej��-✓ ,�rie <br /> � g4z0� <br /> � City: — e� State: �,V� Zip: � <br /> Mailing Addres�- (i(diNerent): <br /> Ciry: __ __ State: Zip:_ <br /> EmaiL•_ll�Qu�J(�r ��MAi���- Phone: (N�� 3/7'G77� <br /> I, ' Total Cost to Install Device(Irom contracfor invoice); S �`I �'1� � <br /> � <br /> i <br /> I, the property owner, requesl to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at ihe above referenced praperty 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 lo the vendor, I agree to lhe (ollowing: <br /> i <br /> , 1. I will not receive a rebate check directly (rom the City of Everett. <br /> � 2. Assigning payment of lhe rebale lo the vendor does not exempt me From Backwater <br /> Prevenqon Device Rebate Program requiremenls. <br /> I aulhorize Ihe release of my rebale to thc vendor listed on ihe back of this form pending <br /> approva � , npleled ckwater Prevention Device rebafe packet 6y the Cily of Everetl <br /> � <br /> / <br /> ' 3 -�/� <br /> S natur Propi�Ay Owner Date <br />