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i <br /> � <br /> , <br /> I <br /> ; <br /> � gackwater Prevention Llevice Rebate �Program � <br /> Vendor Payment Option Form , <br /> Project Number: _ (Cit,fo Provide) <br /> i <br /> � <br /> Please complete both sides of the form ' <br /> � <br /> Property Owner Section: ; <br /> - -- -- — ` f <br /> Property Owner Name: � xC�� �C ���L�_�)I�___—_ I <br /> Installation Addiess: �_���_1[�p�i�__.�"_ � <br /> � � � �J q�avr " <br /> Cily: �- �� Statc: lni�� l�p' - I <br /> Mailing Address(if diNerent}: ____ , <br /> Ciry� Slate: Zip: ' <br /> Email: _ _ __Phone: ( ) _ <br /> Total Cost to Install Device (from contractor invoiceJ: 5��� � ��j�� ___ <br /> �4-�31'��-s'— <br /> I, Ihe property owner, request lo have the City nl Everett Backwater Preven6on Device rebate check <br /> for Ihe installation of ihe device at ihe above referenced property address be made payable to, and <br /> senl to, Uie vendor speafied on Ihe back of lhis lonn. By reques6ng Uie rebale check be made � <br /> payable to the vendor, I agree to the toilowing: <br /> 1. I rrill not rer.eive a rebate check dl�eclly(rom Ihe City of Everett � <br /> 7. Assigrnn�payment of the rebate to thc vendor does nol exempt me from l3ackwater , <br /> Prevention Devicc Rebate Program rcyuiiements. <br /> f- --- �----- ------ --- - - -----_ .. .--- � <br /> I aulhortre Ihe release of rny rehale to Ihr�vendor lisled on the back of this form pending <br /> approval of lhe completed Backwater Prevention Device rebale paoket by lhc Gity of Evercll <br /> A � e <br /> � /(, � / .��— �� ��. �.J <br /> [. <br /> SignaWre of Property wner Date <br />