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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (City to Provide) <br />Please complete both sides of the fo�m <br />?roperty Owner Section: <br />Properly Owner Name: _ `�Q�M V'� �/u �S <br />Installalion Address: �< <O � i <br />c�ry: �VP.VR.�' <br />Mailing Address (i(di/lemnt): <br />U�� <br />Slate: U`�� Zip: -( O�' <br />City: � State:--y��� Z�P� <br />Email: �.QklilUl 1�16�ifa/ C411YtCG�1�1'•� Phone: �) 23�l �dZ 7i <br />Tolal Cost to Install �evice (from contractorinvoice): S �a , q� <br />I, the property owner, request to have the Cily of Everett Backwater Prevention Device rebate check <br />for the inslailation of the device at lhe above referenced property address be made payable to, and <br />sent lo, the vendor specified on the back of this form. By requesting the reba[e check be made <br />pa��able to the vendor, I agree to the following: <br />1. I will nol receive a rebate cher,k directly (rom 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 />I aulhorize the release of my rebate lo the vendor lisled on.the back of this form pending <br />approval of the completed Backwater Prevention Device rebale packel by the City of Everett <br />Signalure of Property O�vner <br />•3 2�t l� <br />Date <br />._. �g±�,�'�,�„���� <br />'�'`�°�1Y ' .�d' '-5.�''d!",�^r,:':+m.x,r.iY�'i., ..-�`+ti3x.x.q�m-ft e�..� - ��r�f��''.".'z' ueair+ao� 6twi'i/h'P�}'R .��°''';� <br />w..a.,....._.. . . f ..:�. r] <br />....x r..�,-_....:KSS�.�h�' .,.._:I:wk.wtt*�&f,..:�..�r f _._..�....r*•+Mt;tllYa► <br />