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' i <br /> Backwater Prevention Devire Rebate Program � <br /> � Vendor Payment Option Form ` <br /> i <br /> Projecl Number: _ (City to Provide) i <br /> i <br /> Please complete both sides of the form � <br /> Property Owner Section: ' <br /> -- i <br /> � Property Owner Name � �� ' <br /> ��� � �,p � <br /> Installation Address: �9_1 ���F-�=f +��- - — l <br /> I <br /> City: ��]�,(�� State:��_Zip: �dT7' � <br /> Mailin j Address(i(d•'Nerent): -- <br /> City: Stale: Zip: ' <br /> i <br /> Email Phone: �),,�_(�_���_ ; <br /> Total Cost to Inslall Device (from conlractor invoir.e): S �o i�(_��C1 � <br /> I, the propery c�vner, reque�t to have Ihe Ciry oi Everett Bac4cvlater Prevention Device rebate check i <br /> for the installaGon of the device al the above referenced property address be made payable ro, and � <br /> sent to, !he vendor specificd on the back of this form. By requesting tho robate check be made r <br /> payable lo lhe vendor, I agree lo the following: II <br /> 1 I will not receive a rebate check direcUy from the City of[vereiL j <br /> � <br /> 2. Assigning paymenl of the rebate to the vendor does nol exempt me from Backwater � <br /> Prevention Davice Rebata Program requirements. � <br /> ----- - I <br /> --- - — t <br /> I authorizc Ihe release of my rebate to ihe vendor listed on the back o{this torm pending ( <br /> approval of ihe completed Backe:ater Prevention Device rebate packct by Uie Gity oi Everett � <br /> I <br /> i <br /> i <br /> .�- � <br /> , ��� �y,� .- �_� � <br /> , <br /> Signature of Property ONmer Date 7 <br /> a <br /> � <br />