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� <br /> , Backwater Prevention Device Rebate Program <br /> �i �, Vendor Payment Option Form <br /> I�� Project Number._ ___ ____(Ciry to °rovide) <br /> , Please complete both sides of the form <br /> I Property Owner Section: <br /> , — -- -- <br /> � Property Owner Name� ��`rG e''J�� <br /> I InstallationAddress: 2-I I"-7 V�/�e.'fv�nD�e.. 1A�/e . <br /> City: L�I-Q-�-2.� Slale: �r�lA _Zip: �l '�i2b � I <br /> Mailing Addross (ildiHernnt): � <br /> City: State: Zip:. <br /> � Phone: <br /> I Email:_ _ _ _ ( ) <br /> I Total Cosl to Install Device((rom contractor invo(ceJ:$��� � <br /> � <br /> I — <br /> I,the property owner, requesl to have 1he City of Everelt Backwaler Prevention Device rebate check <br /> for lhe installation of the device at Ihe above referenced property address be made payable to, and <br /> sent to, the vendor speci(ied on lhe back of ihis form. By requesling lhe rebate check 6e made <br /> payable lo the vendor, I agree to the following: <br /> i <br /> � 1. I will not receive a rebate check directly from the City of Everett. <br /> I 2. Assigning payment of the rebate to Ihe vendor does nol exempt me from Backwaler <br /> � Prevention Device Rebate Program requiremenls. <br /> � I authorlre the release of my rebate to the vendor Iisted on the back ot this form pending <br /> approval of the completed Backwater Prevention Device rebate packel by Ihe City o( Everett <br /> �� -� .��"J�'e-'"' 2 2 � <br /> � <br /> Signature of Property Owner Date <br /> � <br /> � <br />