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� _ - <br /> , <br /> ' • . <br /> I Backwater Prevention Device Rebate Program <br /> � Vendor Payment Option Form <br /> � <br /> � Project Number. (City fo ProvideJ <br /> � <br /> IPlease complete both sides of the form <br /> � <br /> Property Owner Section: <br /> PropertyOwnerName: C_ Nt�O�L t16��'L ihdn 1 ��'��1� �QT �v�15��1 _ <br /> —� <br /> Installation Address: 22d 2 �9 C K E�'G�-L f,'� AJ{, <br /> � City: ��¢i�� Sfate: 1`��• Zip: � D2o� � <br /> I Mailing Address (il differenf): <br /> i <br /> City: State: _Zip: _ <br /> j Email: Phone: (�S) 2Sq `25 D i <br /> � <br /> ' 2g��'• f'� <br /> ! Total Cost to Install Device((rom contractor invoice): $ <br /> I <br /> I I, the property owner, request to have the Ciry of Everett Dackwater Prevention Device rebate check <br /> � (or the installalion of the device at the a6ove referenced property 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 lo the following: <br /> i <br /> I1. I wilt not receive a rehate check direclly from lhe Cily of Everelt. <br /> 2. Assigning payment of the rebale lo the vendor does not exempl me from Dackwater <br /> iPrevention Device Rebate Program requiremenls. <br /> I authorixe the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the compleled Backwaler Prevention Device rebate packet by the Cily of Everett <br /> I <br /> � <br /> �G�2i ��, I"��� � � Z' �1. ' �`a <br /> Signature of Properly Owner Dale - <br /> I <br /> _ _ � <br />