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Project Number <br />Backwater Qrevention Device Rebate Program <br />Vendor Payment fJption Form <br />; <br />(City to Pmvide) . � <br />;:i <br />� , .: .. <br />Please complete both sides of the form ;„': , <br />Property Owner Section: <br />Property Owner Name: <br />Installation Address: /C-�UC(1 <br />City: `� VYL"f" State: <br />Maiting Addmss (if diRerentJ: <br />�C - <br />V�-Iv�lcl. (!�'v4-"� <br />V"�Z�P� ��" J� <br />City: --- S�ate> Zip: <br />Email: �CC':n7 ��1kv��4 (��� [[SL��P„rn�"..-T.�_e.TPhone: (�i2� ���3� � � Z-S� <br />� 1 <br />Tolal Cost to Inslall Device (from conlracforinvoice): $_ �_�j�i� _______ <br />I, the property owner, requesl to have the City of Everett Backwaler Prevention Device rebate check <br />for the installation of the device at Ihe above referenced property address be made payable to, and <br />senl to, the vendor specified on the back o( lhis form. By requesting lhe rebete check he made <br />payablo to the vendor, I agree to Ihe following: <br />1. I will nol receive a rebate check diredty from the Cily of EveretL <br />2. Assigning payment ot Ihe rebate lo lhe vendor does nol exempt me from �ackwater <br />Prevenlion Device Rebale Program requiremenls. <br />i authorizc thc releasa o( my rebate to ihe vendor listed on Ihe back of this form pending <br />approval of the: completed Backwater Prevention Device rehale packet 6y Ihe City of Everelt <br />�-n, . .� ���:�� . . <br />Signature of Property Ow�er <br />�f �,u r��' 2_bf�S <br />l% <br />Dale <br />0 <br />