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Backwater Prevention Devic� Rebate Prograra� <br />Vendor Payment Option Form <br />Project Number. (Ciry to Frovidc) <br />Please complete both sides of the form <br />Property Owner Section: <br />Properly Owner Narne: <br />Instailation kddress: �� ��0 � bv4 ��% <br />—�— <br />Cdy: �(� �� State: ��� Fl" <br />�vlailing Address (il di/ferent): <br />Cily: <br />State: <br />Zip� d � 2�C7 � <br />Email: �7P, —(� ��n (a y� �i �• GDy� ,� PhonQ: (4a5) 31-7-�30� <br />Total Cost lo Install �eviCo (from conl�actor(nv0ice): S�.S'Q'"� <br />I, the propeny owner, request tn have the Gty of Everelt 6a;.icwater Prevention Devlce rebate check <br />tor the installafion of Ihe device at lhe above referenced property address be made payable to, and <br />senl lo, Ihe vendor specified on the back of lhis form. 6y requestiny ihe rebate chec� be rtiade <br />payable lo the vend�r, I agree to the following: <br />1. I vai0 not receiv� a rebate check directly frorn the City of Everett. <br />2. Asslyning paymeni of tho rebate ta Ihe vendor does not exempt m�� trom Backwater <br />Preveniion Oevice ReUate Program requiremenls. <br />I authorize Ihe release of my rQbale lo lhe vendor listed on lhc back of tltis lurm pending <br />approval of U�o compieted t3ackwater pmven[ion Device rebalo packet by the City of Everett <br />%=����If �d' � `-�-� <br />L, — — - <br />Signature of roperty Oivner <br />��?-015 <br />bale <br />