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Backwater Rreventio�� D��vic� <br /> � Rebate Program <br /> For inlemal Use: Project Numbe�: _ _.___ <br /> Vendor Payment Option Forrr► <br /> Please complete both sides of the forrn <br /> Property Owner Section (please print): <br /> f <br /> � S.JS�+J Sol� O2F,� <br /> Property Oadner Name <br /> �1Q__3S4%= ST, ��fi w� aFsZOf <br /> Property Address City State Zip <br /> ; A�temate �vlailing Address City State Zip <br /> I � Zob --715-�(v15 s�so-� sc�o�-�-�a a�',1 �com <br /> I Phone Email <br /> � <br /> I, the Properly Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the installation referenced at ;he PropeRy Address be made payable <br /> ro, and sent to, the Vendor. By requesting tne incentive/rebaie check be made payable <br /> to the Vendor, I agree to the follov;�ing: <br /> 1. I avill not receive a Backwater Prevention Device rebate check direcUy frum the <br /> City of Everett. <br /> 2 Assigning payment of lhe Ciackwater Prevention Device rebate to the Vendor <br /> does not exempt me from Backevater Prevention Device Rebate Program <br /> requirernents. <br /> I authorize the release of my rebate to the Vendor listed on page h•eo of this form <br /> pending apnroval of the completed Backwater Prevention Device rebale package by <br /> the Cily of Ev�rett <br /> � � � �'��� I�2��� <br /> Signaturo of PropertV Owner •Date <br /> � <br /> Revised �1312014 ``9e � °�2 <br />