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f <br /> ; Backwater Prevention Device Rebate Program <br /> ; �r Vendor Payment Option Form <br /> Project Number: _ (Cirylo Provide) <br /> Please complete both sides of the form <br /> i Property Owner Section: <br /> i <br /> i <br /> � Property Owner Name: i� ��-.!'�' � <br /> InstallationAddress I�ZZ ����- ��^^��—' <br /> City: �,_WJ'��T State:�_Zip: `��JZQ7l <br /> �� Mailing Address(il dillerenf): <br /> I <br /> � City: State: Zip: <br /> I <br /> i <br /> I Email: /i���,r�� �}�"'"� � ✓` Phone: (�{Z� °'7Cr — �:C)G,� <br /> i Total Cost lo Install Device (Irorn confracfor invoice): $� tce. / <br /> I <br /> I I,the property owner, request to have the City of Everelt Backwater Prevenlion Device rebale check <br /> for Ihe inslallalion of the device at the a� ee referenced properly address be made payable Io, and <br /> sent to,the vendor specified or�the back„i lhis(orm. By requesting the rebate check be made <br /> I payable lo the vendor, 1 agree b lhe following: <br /> � t. I will not receive a rebate check direcUy from the City of Everei! <br /> I2. Assigning paym�nl ot the rebate to lhe vendor does nol exempl me from 8ack�vater � <br /> � Pcevenlion Device Rebnte Program requirements. <br /> I <br /> � I aulhorize the release of my rebate to the vendor listed on Ihe back of this(orm pending <br /> � approval of the compleled Backwater Prevention Device rebate packet by the City of[veretl <br /> i <br /> , G� �/���4-�q/� I -Z� -ZOls <br /> Signature of Property O�vner �ale <br /> � <br /> � <br />