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i <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment uption Form <br /> Projecl Number. (City(o Piovide) <br /> Piease complete bofh sides of the form <br /> Property Owner Section: <br /> Property Owner Name: _G-ec r (7��_[I CZ• �l-9 C�'�'� <br /> 9� i � <br /> Inslallation Address: ��.2 //iGt/1J/$- ��/ <br /> � � q �-�/ <br /> City: �_(�'2/� Pi�� State: �G� Zip:,_.� _ <br /> Mailing Address (i(diBerent): _ <br /> City: _ State: Zip: <br /> � Email: Phone' ( ; <br /> Total Cost to inslall Device (Irom contractorinvoice): S __ <br /> � <br /> I, the property owner, request to have the City of Everett Back�vater Prevention Device rebate check <br /> (or ihe installation of the device at the above referenced property address be made payable b, and <br /> senl to, the vendor specified on the back of lhis form. �y requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will nol receive a rebate check direr,tly from Qie Cily o(Everelt. <br /> 2. Assigning payrnenl of lhe rebate to the vendor does not exempt me irom Backwater <br /> Prevenlion Device Rebale Program requirements. <br /> I authorize thc relcase of my rebate to thc vendor listed on the back o(Ihis form pending <br /> approval ol lhe completed Backwater Prevention Device rebate packel by the City of Everetl <br /> �,,����?� ��zt,�r�'t-- e�- -�2�i�—�� <br /> a <br /> Signature of Property O�vner Date <br />