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Backwater Prevention Device Reba �errP�`o9ram <br />Vendor PaYment t�pi�on Fo <br />Project Number: <br />{Crty to Provide) <br />Please comptete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />installation Address: -" <br />State: Zip: � � - -- <br />City: ��� � <br />Mailing Address (if differeni): <br />City: <br />State: <br />Emai1: <br />Tofial Cosk to 3nstall Device (t'rom contractor involcej <br />Zip: <br />Phone: �'� a� "` �� <br />� �1.�-� 1 . S7 �2 _ <br />l, the property owner, request to have the City fe� p� sope�ytaddress bte m ds payable� ocand� <br />for the installation of the device at the above re R <br />sent to, the vendor specified on the b oik��'�h�s form. By requesting the rebate check be made <br />paya b le to t h e v e n d o r, 1 a g r e e t o t h e f 9 <br />1, 4 wi l V na t r e c e i v e a r e b a t e c h e ck directl y from the City af Everett. <br />2. Assigni�g payment of the rebate to the vendor does not exempt me fram Bac4cwater <br />prevention Device Rebate Program requirements. <br />1 authorize the release of my rebate to {�e entlon�Devic�e rebate packet by the Cipy of E erett <br />approva 4 a f t he c o m p i e t e d B a c k w a t e r P r e v <br />��.�,�.�- _ �_ <br />� �� �� <br />Date <br />Signatur� of Property Owne <br />