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� gackwater Prevention Device Rebate Program <br />Vendor P7yment Uption Fornrr <br />Project Number. _. (City to Providr�) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property0evnerName: l_�+ F��» ^-"9 y�`'`�^'�" "v•'•'""""^ <br />Installation Address: ���o V' ��� ^��� ^v� <br />City: _� vrv1�T- ; — State: W� Zip: 9� z �� <br />Mailing Addiess (il diflerent): <br />City: _ Slate: �ip: <br />s,,.,. <br />Email: � � a�++'1Grn . �e. ' Phor.e: (y� 25'9 - �s8 f <br />Tolal Cost to Inslall Device ((rom contractor Invoice):$ �- foG �` _ <br />I, lhe property owne�, requesl to have lhe City o( Everett Backwater Prevenlion Device rebate:check <br />for ihe Installation of the device at lho above ie(erenced property address be made payable to; and <br />sent to,lhe vendor specified on the back of this torm. By requasting lhe rebate check be made <br />payahle to lhe vendor, I agrec to the following <br />1 I will not receive a rabalo check directly from ihe City of [veretl. <br />2. Assigning payment of the rebate lo the vendor does not exempt mc from Backwater <br />Prevention Device Rebale Program requiremen�s. <br />I aulhoriz� lhe release of my rebate lo the vendor listed on the back of this form pending <br />approval of the compleled Packwater Prevention Device rebate packet by the Cily of Everetl <br />Signatur� �( Property Owner <br />2 /� <br />Da! <br />