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�Backwater Prevention Device Rebate Progr�m <br />Vendor Payment Option Form <br />Pro�eCl Number __ __ (City to Provrde; <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name. _(�. -,r�� -- l� � � � � = �. .�- — - <br />. <br />Instaliation Address �l L� C. r c�. sr e•'__�� _, <br />City l' ,.,+r. %�" -- -- — State . �+• •�_ Zlp - <br />Maiiing Address (d diHerenq <br />Gty - ---- -- - State Z�P — --. --- <br />Emali' /Y!W ' ' �f. r� �✓. --- - ---. Phone 14J4__:.��,._cbc�3 <br />Total Cost to Install Device i lmm contraclur utvorce) S �� �1�� � � <br />—T-- --- — <br />L <br />I, the property owner. requesl to have the Crty of Everett Backwater PrevenUon Uevice tebate ChaCk <br />for lhe mslallation of the tlev�ce at Ihe above referenced property atldress be made peyable to, and <br />SQflt l0, th� V@�d0� SpeCil�Etl On lh0 baCk OI (hi5 tOrrii By requesting the reoate check be made <br />payable tc Uie vendor I ag�ee lo the following <br />1 I wdl not receive a rehate check direcUy from Ihe Gly o( [verett <br />2 Assigning pay�nent ot ,ha rebate to the v�r.tlor ooes nct exempt me trom Backwater <br />PfeveMion Dewte Reba�e Program requuemenls <br />I author¢e Ihe release of my rebate to the ventlor Ilsted on Ihe back of this form pending <br />approval of Ihe completed Backwater Prevention Dewce rebate packet by the Ciry of Fverett <br />Si�;nature �f Property Owner <br />! � `� � <br />-- � ' � -- <br />� � <br />Date <br />i <br />