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� _. _._ _ __ - - _ . — _ <br /> _ _ <br /> I <br /> � <br /> I <br /> � Backwater Prevention Device Reb.�te Program <br /> iVendor Payment Option Form <br /> i <br /> Project Number. _ (City to Provide) <br /> il Please complete both sides of the form <br /> Prope�ty Owner Section: <br /> I _ <br /> � Property Owner Name: /�cGr'7 p/!., Sec n4n _ <br /> � InstallationAddress: J1/� /Lc�r;k,t'/ <br /> I <br /> 1 City:�vere.f� Slate: InrA Zip: l�l�/ <br /> � Mailing Address(if diHerent): <br /> City: Slale: Zip: <br /> iEmail: _�a,r-n!�'Jil1LAC, c'C�� Phone: (�) 3a3— ���� <br /> Total Cost to Install Device (from contracfor invoice): $ �,,;ec'• � <br /> I <br /> � I,the property owner, request lo h.:ve the City oF Everett Backwater Prevention Device rebate check <br /> ' for thc installation o(the davi�e at lhe above referenced property address be made payable to, and <br /> � <br /> � sent lo,the vendor sper.ified on �he back of this form. 8y requesting the rebale check be made <br /> pay�ble lo lhe vendor, 1 agree to Ihe following: <br /> 1. I wiil not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment o(the rebate lo ihe vendor does not exempt me from Backwaler <br /> Preven�ion Device Rebate Progrem requirements. <br /> I authorizc the relcese ot my rehate ro the vendor lisled on the back of this form pending <br /> approval of the completed Backwater Preven�ion Device rebale packet by ihe City of[verett <br /> I <br /> -,J��/a ��-ru��---.. �� ..�.,�n.s ; <br /> i <br /> �, Signature o(Property Owner Dale <br /> � -- -- <br /> i � <br /> � <br /> I <br /> � � <br />