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1 <br /> backwater Prevention C evic� IRabac prc�grarn <br /> Vendor <br /> PaymentC1ptio;n 1Farm <br /> i <br /> Projoct Number: (City to Provide).. <br /> i <br /> 'lease corriplete both sires of the form <br /> Property Owner Section: <br /> Property Owner Name: �QSSAtir` � CQ <br /> lnskallatron <br /> Address: --c` <br /> City: vt State: 4�G. Lip: <br /> Mailing Address (if different). <br /> a <br /> City: State Zip. <br /> small; I?hone: <br /> 7777777. <br /> Total Cost to install Device (from contractor invorce) $ `) <br /> a. <br /> I,the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to,and <br /> sent to,the vendor specified on the back of this form. 13y requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. 1 will not receive a rebate check directly from the City of Everett. <br /> a <br /> 2, Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements; <br /> E authorize the release of my rebate to the vendor listed on the back of this form pending a <br /> approval of the completed Backwater Prevention.Device rebate packet by the City of Everett. i <br /> 2S �� <br /> Signature of Property Qw <br /> ner. Date; <br />