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I <br /> • I <br /> Fackwater Prevention C�evice <br /> ��T Rebate I�r�o r <br /> � g am <br /> I <br /> For internal Use: Pioject Number. ____ <br /> Venclor �ayment Option Form <br /> Please complete both sides�of the form <br /> Property Owner Scection (please print): ' <br /> _. I <br /> Property Otvner Name I <br /> � <br /> �o����uJ . ����l1 <br /> Property Address City � State Zip <br /> �� �S Rvcke� a� Eu��et i C�1d � o I <br /> Hllemale tviailing Address City � State Zip <br /> I <br /> Phone Email <br /> — I <br /> � <br /> i <br /> I, the Property Owner, reyuest to have the City of [verett Backwater Prevention Device <br /> reb�te check for the installation referenced at the Property Address be made payable <br /> to, and sent to, the Vendor. By rc�questing the incentive/rebate check be made payable <br /> ta the Vendor, I agree to the tollowing: ' <br /> I <br /> 1. I will not receive a l3ackw�ater Prevention Device rebate check directly from the <br /> Cily of Everett. <br /> 2. Assigning payment oi the Backwater Preventioii Device rebate to the Vendcx <br /> does not exempt me from Backw�ater Preventioii Device Rebate Program <br /> requirements. <br /> � <br /> I authori�e the release o(my rebr�ti� to Ihe Ve�dor list�:d on page two of this form <br /> pending approval of the conyileled E3ack�•,�atcr Prevention Device rebate package by <br /> lhe Ciry of Everett � <br /> i <br /> �j ; ' <br /> `�-`—�..��.,lJ - 3 • 30� ZorS <br /> Siynature of Propei Qy�ner � Date <br /> �_. <br /> i <br /> � <br /> Revised 91312014 �'age t o(2 <br />