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i _ <br /> � <br /> � <br /> ; Backwater Prevention Device Rebate Prygram <br /> � � Vendor Payment Option Form <br /> � <br /> � Project Number: __ _ (City to Provlde) <br /> I <br /> Please complete both sides of the form <br /> � Property Owner Section: <br /> I <br /> Property O�vner Name: U� � ��'" _ __ <br /> Installation Address: � GLJ ��� ��"'— <br /> City:�� State: ��" Zip:�/ �� <br /> Mailing Address (if diKerent):__ <br /> � <br /> Ciry: State: Zip: <br /> EmaiL• " . Phone:.�. .. ' . <br /> Tolal Cost!o Install Device(lrom contractorinvoice):$ ��t"�J'L• �� _ <br /> . ., . _ . .. . ._ <br /> I,the property o�vner, requesl to have the Ciry of Everelh8ackwater Prevention Device rebate check <br /> � for the installation of the device at the above referenced propeAy address be made payable to, and <br /> sent:o,the vendor specitied on the back of this form, By requesting the rebate check be made <br /> payable to the vendor, I agree to theJollo�ving: <br /> 1. I will nol receive a rebale check direcUy from Ihe Cily of Everetl. <br /> 2. Asslgninp paymenl of lhe rebale lo lhe vendor does nol exempt me from Backwaler <br /> Prevention Device Rebate Program requirements. <br /> � I aulhoiico lhe release o1 my rebate to the vendor lisled on lhe back oi this form pending <br /> i <br /> approval oi the completeA Backwaler Prevention Device rebate packet by lhe City oF Everett <br /> � , '���. � � �y���� <br /> �L(� <br /> �ignature ot Property Owner Date <br /> I <br /> � - --- _ _ _ <br /> _ — - - - - - . _. _ _ <br /> - - <br />