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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />project Numbcr. (C�ry fo Pmvidc) <br />Please complete both sides of the form <br />Property Owner 5ection: <br />properfy Or+ner Neme: ���i � ���!�L'LL� /.�t f �c' <br />InstallationAddress: ��� (.�b�� //y� <br />c��Y: �v ��:�rr s�,�: Lu�%i- z�p: �'��� <br />t�laiting Address (11 drtlerenQ: <br />Gity: 5tatc: Zip: <br />Emaii: _ �� �.� �'•t� �Lw�Yfl,.� � C�+'t Phone: ����'�%� <br />Total Cost to �ns1aU Device (/rom contracforinvoice): 5 2r,�o ,/' <br />I, tho properiy owne�, request to have lhe City of Evorotl Backwater Prevention Oevice rebate checY. <br />tor the installatipn of the device al the above ro(eren�ed praperty add�ess t�e made paya6le to, and <br />sent to, the vendar specihed o� ihe back oi this (orm. By royues6ng the rebato r,heck be made <br />payabia to the vendor, 1 agree to ihe lolla�ving: <br />1. I wdl not receivo a reb�te oheCk direcUy frbm lhe Gily of Everett. <br />1. Ass�gnmg payment of Ihe rebate to the vendor does irat exempl me irom Hacke+ater <br />Prevention Device Rabata Progrem req�iremenls. <br />1 aulhorize the releasc oF my reb8to to Ihe vendor lisled on the back ol Ihis (orm peodin� <br />approval of lhe completed.Backwater Prevenbon �evice rebato packet by lha City of Everetl <br />� ���:1 l �,�..�..�'`"L.- .�a /S� <br />Slgnat re of Property Owner Date <br />