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Project Number. <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />_ (City to Prvvide) <br />Plc ase complete both sides of the form <br />� - Property Owner Section: <br />Property Owner Name: �%,�G Cl y�;f r�7 T L� (,,n <br />InstallationAddress:_ 3(�7�, �I�c(1C�.���P�lP1'' �rt': <br />City: .�Yi�C-(�`f' -- State: 1 � ''T Zip: �p 7Cl � — <br />, <br />Mailing Address (if dilferenf): __ <br />Cify: _ State:� Zip: <br />Emalt :.. Y) U(� G 1'C� G1 rl t.� O� iY1Gf !I •�UlYlPhone: ('-i��� ��� <br />W <br />Total Cost to Install Device (lrom confraclor invoice): $__� 'i �Z�O�. <br />I, the Froperty o�,vner, request to have the City oi Everett Backwater Prevention Device rebate cneck <br />forthe installation of the device at the above referenced propeity address be made payable to, and <br />senl lo, the vendor specified on the back o( thls form. By requesting the rebate check be made <br />payable,to the vendor, I agree to the following: <br />1. I v.�fll nol receive a rebate check directly hom the City of Everelt. <br />2. Asslgning payment of the rebale to the vendor does not exempt me irom Backwator <br />Prevention Device Rebale Program reauirements. .� <br />I authonze the release of my rebate to the vendor lisled on Ihe back of lhis forn pending � <br />approval of the completed Backwater Prevention Device rebale packet by Ihe Clty of Everett <br />� I <br />�l"L ,� <br />Signature of Prop`erty O�vner <br />�I.J � %7 ,7/1 <br />Date <br />r. <br />w �;:. <br />