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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Numbec _ (City (o Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: (-}�el'� G� )(�Q a � J• LTD�_LS�L� <br />U <br />�nsta��ation nddress / %I3 �C)7`�t�^-Q-e.r <br />city:_(�/�} state��'�' .zip: ��fZEJ/-L2ZZ-9 <br />Mailing Address (il diNe�entJ: <br />City: _ State: Zip: <br />Email: �,�L�'7 �� C ���5% h�-( Phone: �f � J� -r1�J l Z <br />! <br />Tolal Cost to Install Device ((rom contracfor invoice) $ __ <br />I, the properly owner, requesl lo have the Cily ot Everetl Backwater Prevention�Device rebate check <br />for lhe inslallation of lhe device at the above referenced property address be made payable to, and <br />sent lo, the vendor specihed on lhe back of this (orm. By requesting lhe rebale check be made <br />payable lo lhe vendor, I agree lo the tollowiny: <br />1. I will not receive a rebate check direclly from the City of Everett. <br />2. Assigniny payment o( the rebate to Ihe vendor does not exempt me (rom Back�vater <br />Prevenhon Device Rebalc Program requiremenls <br />I aulhorize Ihe release oi my rebal�a to the vendor Ilsled on thc back of this form pendin9 <br />approval of the compleled Backwater Prevenhon Device rebale packel by Oie Cily of Everetl <br />� — <br />�- � 1-ao-;s <br />ig aWre ot PropeRy O�vner Date <br />