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r1 . • <br /> � Backwater Prevention Device Rebate Program <br /> Vendor PaymF�nt Option Form <br /> ProJect Number, ______(City fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ��� Ll�� � �S eY�l <br /> Instaliation Address: '� 1 �( l � )P-i-✓�'� U2 r'1�/C_ <br /> City:_� 1�,�,Z'� Slate: � A IW. ZiP:�� � ( <br /> Mailing Address(if diHerenf): <br /> City:���y` P'TT— Stale: �A Mr 2ip: � 2S �G � <br /> Email: `S ��yY�,,,��� ��t"a 4# . N .� Phone: ( z�,2�/3 S S�Z <br /> J <br /> Total Cost to Install Device(from confractor Invoice): $_ <br /> I, the properly owner, request to have, the City of Everetl Backwater Prevention Device rebate check <br /> I for lhe installation of the device al the above rcierenced property address be made payable to, and <br /> senl to, lhe vendor specified on ihe back of this form. By requesting the rebale check be made <br /> payable to the vendor, I agree lo the following: <br /> 1. I will not receive a rebate check diredly from lhe Ciry of Everetl. <br /> 2. Assigning payment of the rebatc to Ihe vendor does not exempt me from Dackwaler <br /> Prevenlion Device Rebate Proyram requiremenls. <br /> I authorize,ihe release of my rebale lo lhe vendor listed on the back ot this torm pending <br /> iapproval of Ihe completed Backwater Prevenlion Device rebate packel by Ihe City of Everetl I <br /> � <br /> 1 <br /> � � zz/5 <br /> Signature of Property Owner Oate <br /> I <br /> � <br /> � <br /> I <br />