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a <br /> � Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Forrn <br /> Project Number: (Cify fo Provide) <br /> Please complete both sides of the form <br /> � <br /> Property Owner Section: <br /> Property Owner Name:��(� 1�' �1 ` C� <br /> �� Inslallation Address: [/��D 1 Q/t���t�G� ��� l./'i ) <br /> I City:����• State: � 1 ZiP: �� <br /> � Mailing Address(if diHerent): <br /> � <br /> City: State. Zip: <br /> Email:�l��,�' `�IIIP/1������YY�Ctv�. Phone:�'� �� <br /> Total Cosl to Install Device !from contracfor invoice): 5 t��'���' � <br /> ' I, the property owner, request to have the City of Everett Backwater Prevenlion Device rebate check <br /> for the inslaliation of lhe device at the above referenced propeAy address be made payable to, and <br /> senl to, the vendor speci(ied on the back of this form. By requesting lhe rebale check be made <br /> payable lo the vendor, I agree lo the following: <br /> t. I will not receive a rebale check direclly from lhe City o(Everett. <br /> 2. Assigning payment ot lhe rebate lo the vendur does nol exempt me from Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> 1 authorize the release of my rebate to Ihe venAor f sted on the back of Uiis form pending <br /> approval of the completed Backwater Prevenlion Gcvice rebale packel by lhe City of Everetl <br /> (�`��'��Vi�'��'_1,��-- ��1511� <br /> Signature ot Property Owner Date <br /> ( <br />