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ackwater Prevention �vi�e Rebate Program <br /> Vendor Payrr�ent ption Farm <br /> Project M1lumber: (Cify to Provide) <br /> Please complete bo�h sides of the form <br /> � <br /> Property Ov�rner Section; <br /> Property Owner Name: '�-��...� � � . �.��,��{._ ��i�. � ��,.,� <br /> Installation Address: ���,��, �..��� ��� <br /> a. <br /> �`��-' ; <br /> City: �i't�'f�t'�..��" State: ��*�� Zip: � ��...� 1 � <br /> s <br /> Maifing Address (if differenf): ��i-" � <br /> City: State: Zip: <br /> L��� <br /> Email: l��,k�����`"°ti�r'}C'���� ��i �Y�'�t C��"°�� Phone: � ) ���� :�t.;�-�', <br /> � <br /> Total Cost to Install Device(froin contractorinvoice):$_--��t=-as�� I" <br /> l,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 rriade payable to, and <br /> sent to,the vendar specified on the back of this form_ By requesting the rebate check be made <br /> payable to the vendor, I agree to the foliowing: <br /> 1. I will nat receive a rebate check directly from the City of Everett. ' <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater � <br /> Prevention Device Rebate Program requirements. <br /> �. <br /> � <br /> � <br /> I authorize the release of my rebate to the vendor iisted on the back of this form pending � <br /> approva! of the completed Backwater Prevention Device rebate packet by the City of Ever�tt � <br /> � ��- ,, } � .�;� `� ��F t� <br /> �''��``'°� v f�' ' <br /> �. <br /> 5ignature of Property Owner Date <br /> E <br /> � <br /> � <br /> i <br /> � <br /> � <br /> � <br /> i <br /> � 1' <br /> i <br />