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i <br /> ; <br /> , <br /> � Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> � Project Num6er. (City ro Pmvide) <br /> i <br /> i <br /> � Flease compiete both sides of the form <br /> iProperty Qwner Section: <br /> I — <br /> i . <br /> � Property Owner Name�r___ � �� � ,n� � E,��,p l 1 ?�C.S <br /> I Installation Address: Z� I I ��r,.� �.-ti rp( �Q J �, I <br /> I C �Q �j-� � <br /> j Cily: L 1��P �� State: w J� Zip: � D v0I <br /> ; Mailing Address (if di(ferent): Z T I �G 1�-p l � ✓�2 <br /> i Gity: � U�e�'_ State:�Zip: 9 �S'Zo � <br /> � Email:�m n� 01 i B,r� A 2 � /�'� S r/• c o rv� Phone: (yy� �3� - 6 I 12 <br /> ITotal Cost to Install Device ((rom contractorinvorce): $ <br /> � <br /> I -- <br /> � <br /> i <br /> I, the property ovmer, request to have the City oi Everett Backwater Prevention Device rebate check <br /> I for the installation of lhe device at the above iefa�anced property address be made payable to,and <br /> I sent to, the vendor specified on the back cf this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the foilowing: <br /> 1. I �vill not receive a rebate check directly from the City of Eve�ett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize the release of my rebate lo the vendor listed on ihe back o(lhis form pending <br /> � approval of the completed Backwater Prevontion Device rebate packet by the City of Everett <br /> � <br /> ! � � � � <br /> , <br /> Signature of Property Owner Oate <br /> I <br /> I <br /> i <br /> � <br /> I _ _ _ _ _ _ <br />