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BackwaYer NrevenYion Dev►ce Rebat� Program <br />Vendor Payment Option �orm <br />Project Num6er: (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: // i c �• v���E <br />Installation Address: _ ��n ^ � /�'/� -����- — <br />City: ���u'�" Stale: �/'d` Zip:__ � f� � <br />Mailing Address (ifdiNerent): ������ <br />City: C� � State: _�(�� Zip:_�/(giJN � <br />Email: �QCA_��« :�! C-U�T _ �'hone:'�� ��� ��L� <br />Total Cost lo Install Device (lrom contraclorinvoice): $��'� <br />I, the property owner, requesl to have the City of Everett 13ackwaler Prevention Device rebate check <br />for the inslallation of ihe device at lhe above referenced property address be made payable lo, and <br />sent to, the vendor sper.ified on the back of Ihis form. Hy requesting the rebate check be made <br />payable to Ihe vendor, I agree to the following: <br />1. I will not receive a rebale check direr.tly irom the City ol Fverelt. <br />2. Assiyning payment o( the rebate to Ihe vendor does not exempt me irom Backvdaler <br />rrevenlion Device R�bate Program requirements. <br />� I authorize lhc release of my rebate lo Ihe vcndor lisled nn lhe back of Ihis form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of [verett <br />I <br />i <br />--�-'/��� _ ������ <br />Signature o( Property Owner Date <br />