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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projeci Number. _ __ (City to P�ovide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: R'�"� ���� � Il� � Lo �� �,�z-�� �� 1�,,, ;,,, <br />�-(-O� �u�lct.�r^�� i�.jc S £ ��..�Q„ya I�o <br />Installation Address 3 � �-�.} <br />Gty _�.Jzr�tt- State: t,� � Zip. ��S y c� � <br />Rlailing Address (if diNerenf): �7 �� � �"� � !�`-^� S <br />City: ��t''� � State: '�� Zin: ��� � fr <br />Z 4 <br />Email: e �.�c�-oy..av.� G.�-s n_ c a�--- Phon�. ("� � 9- 2 S- <br />Total Cost to Install Device (from confractorim�oice): $ �°�' �-`�� >pgS.r�S 0 <br />I, the property owner, request to have the City of Everett Backwater Prevenbon Device rebate check <br />for ihe installation of the device at the above re(erenced property address be made payable to, and <br />sent lo, the vendor specified on the back ot this form. By requesling ihe rebate check be made <br />payable to the vendo�, I agree to the following: <br />1. I�vill not receive a rebate check directly irom th2 City of Everatl. <br />2. Assigning payme�t o( Ihe rebate to lhe vendor docs nol exempl me from B,-ickH�atei <br />Prevention �evice Rebate Program requirements. <br />I authorize the release of my rebale to the venJor lisled on the back o( this form pending <br />approval o( the completed Backwater Prevention Device rebate packet by the City of Fverett <br />�i.0 ` � '� "�"( , r---- <br />V <br />�i�li��� <br />Signature o` Property Owner Dale <br />