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/,���q Backwater Prevention Device Rebate F'rogram <br /> �iw��rr Vendor Payment Option Focm <br /> �.� <br /> Project Number: (Ci1y fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: C' I _�����)A�'Lhn C'k'� <br /> Installation Address: l�O� �I,tLKU' <br /> c�ty:�vere�l-k- Stale: Wa z�P: QSaD ( <br /> Mailing Address (i!di(lerent): <br /> City: Stale: Zip: <br /> Email: ____ Phone: ( ) <br /> Total Cost to Inslall Device (Irom contractorinvoice): $ LQ4,3�• r�Q <br /> I; lhe property o�vner, reguesl lo have the Ciry of Everett Back�vater Prevention Device rebate check <br /> tor the installation o(the device at the above rcferenced propeAy address be made payable to, and <br /> sent lo, the vendor speci(ied on ihe back of this (orm. By requestiny lhe rebale check be made <br /> payable to lhe vendor, I•agree to lhe following: <br /> 1. I will not receive a rebate check directly irom lhe City of Everett. <br /> 2. Assigning paymenl of lhe rebate to the vendor does nol exempl me from Backwaler <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of lhe completed Backwater Prevention Device rebale packet by ihe City of Everett <br /> �,�, � � � �- �s <br /> Signature of Property wner Date <br />