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I�I Backwater Prevention Device Rebate Program + <br /> , �r Vendor Payment Option Form � <br /> , � � <br /> � <br /> Project Number: (Cify to Provide) <br /> ..� � <br /> I Please complete both sides of the form <br /> I <br /> ' Property Owner Section' ' <br /> ; , <br /> � . i <br /> � Property0wnerName: �(�i�/JiJ �)2C.IZ/�/'�- ___ ____ j <br /> � Inslallation Address� _� ✓ /_1di���.t.��°/� — �d� — � <br /> ' ^ � —�Ul!"� <br /> City: �L.'P�' Slate: �_Zip: <br /> ; Mailing Address(iI dilterent):�?���q �G /v� <br /> , City: fU State: /!).�__Zip: '�Il��2� <br /> i Email: ('s�v�1�/'l7Jll/ �err� Phone: (�C�) 6.l ��/�- <br /> � Total Cosl to Inslall Device(f�om confractor invoice): 5�1 �J . /�n <br /> I,the property owner, request to have the City of Everett Backwater Prevention Device r�bate check <br /> for the installation of the device at the above referenced property address be made payable to,and <br /> senl to,lhe vendor specified on the back of this form. By requesling ihe rebale check be made <br /> ; payable to the vendor, I agree to the following: <br /> 1. I �vill nol receive a rebate check diredly irom the i,ity ot Everelt <br /> � 2. Assigning payment of lhe rebale lo the vendor does aot exempl me from Backwaler <br /> IPrevention Device Rebate Program requirements. <br /> i <br /> I � I authorize the ralease o!my rebate to the vendor listed on the back o(this form pending <br /> approval of the compleled Backwaler Prevr,ntion Device rebale packel by Ihe Cily of Everett <br /> i <br /> � ���� �- o��/ <br /> Signature oi Property Owner Date <br /> � <br /> I <br />