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_ _ - -- - --- --- _ - -- ---___.---� <br /> ------- -- __ - <br /> � - -_ _- <br /> I <br /> I Backwater Prevention flevice Rebate Program <br /> ' Vendor Payment Option Form <br /> Projecl Number: (City to Provide) <br /> I P. �e comptete both sides of the form <br /> I <br /> � Prope►ty Owner Section: i <br /> .' <br /> PropertyOwnerName: �(v�� '�L���y �u�G� I <br /> Installation Address: /�l� � �N s� <br /> ' Cily: �r.�y� State: _ t��_Zip: ��Z D/ I <br /> I <br /> Mailing Address(ifdifferenQ: — I <br /> � City: State: Zip: I <br /> i Email: Phone: (�ZJ7 Z5! � �9SL <br /> � Total Cost to Install Device (from contractor invoice): $ �SOO , � <br /> i , <br /> � I, lhe 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 property address be made payabie to, and <br /> � sent to, the vendor specified on the back of this form. By requesting the reba�e check be made <br /> payable to the vendor, I aaree lo the following: <br /> � 1. I will nol receive a rebate check direc:ly irom the Cily of Everett. <br /> 2. Assigning payment of ihe rebate lo the vendor does nol exempt me from Backwater <br /> C�revention Device Rebate Program req�iremenls. i <br /> � <br /> I aulhorize ihe relea� ; my rebate lo ihe vendor listed on the back of this form pending � <br /> approval of the co �� .. Backwater Prevention Device rebate packet by Ihe City of Everett j <br /> � <br /> ��_, ��� Zi ��ZO/5 <br /> Signalure o(Property Owner Date <br /> � <br /> I <br /> i <br />