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I <br /> � Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> � Project Number. (City to Provide) <br /> Please complete both sides of the form � <br /> , <br /> Property Owner Section: j <br /> i - - ----- -- � <br /> / / i�-i <br /> PropertyOwnerName: :�,;�r�j ' �'t`r / r:(.[� '.'C( � ... <br /> � / � <br /> , Installation Address: i }�/�`� C,� � 'r-1,'v"r' 0 t�-� � <br /> � '`�} �, '�� .� I <br /> I City: �� lTr'�-�"C`��'— State: ��'� { � Zip: '?_)' ! <br /> � A4ailing Address (i(di(ferent): .�±?� %i )��' b�>�• � � <br /> i <br /> �, > �' <br /> City: `�� Y�7Gr i i State: li✓�`{" Zip: �yi% <,Z-�• <br /> _/; �_ � • �` <,� C�/ <br /> i Email: ,!y � ��7f Gv`, �J ; �l41G'. /0/j^ Phone: (d.�e) v � • 3 , 1D <br /> Total Cost to Install Device (from confracMr invoice):S o���S o.�� <br /> � - <br /> � I, Ihe property owner, requesl to have the City oi Everett Backwater Prevention Device rebale check <br /> � for lhe installation of the device at lhe above re(erenced property address be made payable lo, and <br /> I senl to,the vendor specified on the back of this(orm. By requesting lhe rebate check be made <br /> payable lo the vendor, I agree lo the following: <br /> � 1. I will not receive a rebale check direclly from ihe City of Everelt. <br /> I 2. Assigning paymenl of lhe rebate to the vandor does nol exempt me(rom Back�vater <br /> Prevention Device Rebate Program requiremenis. <br /> i <br /> i <br /> I aulhorize lhe release of my rebale to the vendor listed on lhe back of this form pending <br /> approval of the compleled Backwater Prevention Device rebale packet by lhe City o(Everett <br /> � J ,�..�''.> %/ � � ' ` <br /> _. � J+,_ . <br /> i f�^`_' y/�; .. r�..r��,' l�% �b� /V <br /> i' !� <br /> Signalure o(Property Owner Date � <br /> � I <br /> � <br />