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i • <br /> Backwater Prevention Device Rebate Program <br /> ; ��.:�"�", Vendor Payment Option Form <br /> � <br /> Project Number. ___(Gty to ProvideJ <br /> � Please complete both sides of the fortn <br /> Prope►ty Owner Section: <br /> Property Owner Name: Thomas Costello <br /> Installation Address: 1620 WeUnore <br /> City: Everett State: WA Zip:96201 <br /> Malling Address(il di(larent): � <br /> ; Cily: State: 21p: � <br /> Email: mikecostellousa@Rmail.com PFone: (425) 232-6920 <br /> Total Cost to Install Devlce(from contractor invoiceJ: S 2•402.40 � <br /> � I, Ihe property owner, request to hava lhe City of Everetl Backwater Prevention Device rebate check I <br /> for the instellaGon of the device at the above referenced properfy address be made payabie to,and 1 <br /> sent to,the vendor specified on the back ot this form. By requesting the rebate check be made � <br /> payabls to the vendor, I agree to the following: <br /> I 1. I will not receive a rebate check directly from the City of Evereft. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Provention Dovice Rebate Program requirements. ' <br /> I <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending ' <br /> approval of the completed Backwaler PreveMion Device rebate packet by the City of Everett <br /> �� .�� D 1/`�" � \ ��� � �'. <br /> ; �� .� -� <br /> Signature of Property Owner Date � <br /> i II <br /> � <br /> � <br />