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Back�nrater Prev�2ntion Device Ret.iate Program <br />� Vendor Payrrzent Option 1=orm <br />Praject Numbec (Crfy fo Provide) <br />Please complete both side�. of the form <br />Property Owner Section: <br />Properly Owner Name: �gr-h�ne.�"1.t]:i�rrnntlT/L.r!5'E7L1 ��DlYna nh_ — <br />�P.�A Dinm � Venfeu-eS LLC_ <br />InstallationAddress: fa�� I �yt, St _. __. <br />City: �Pie�l-f- State LL1A _Zip: 98.2� I <br />�vlailing Address (rf diNerent): S yG L�` �� �n n� %� <br />City. .� � i-�' State: L()i� Zip: CI$LCi3 _ <br />Email: i—�oivnnn��Je�-�;���%ron�,'e✓. com Phone: (c(z�,319 -L�lle�' _ <br />, o� k.,'s�,'.,e <br />Total Cost to Install Device (from contractorinvoice): $ � �� <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above reterenced properly address be made payable to, an� <br />sent.to, lhe vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the touo�ving: <br />1. I will not receive a rebate check direclly from the Cily of Everelt. <br />2. Assigning payment of the rebate lo the vendor does nol exempt me from Backwater <br />Prev?ntion Device Rebate Program requirements. <br />I authorize the release of my rebate to ;he vendor lisled on the back of fhis form pending <br />approval of the completed Backwater Preevenlion Device rebate packet by lhe City of Everett <br />, �� <br />ignature oF Prope wner <br />�z0 % S— <br />Date <br />