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I <br /> 415.77. ; <br /> • <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: eS--Tt---P <br /> J ) <br /> Installation Address: PO [ C-e-ec' r 3 <br /> City: E_l.Je,r Q-= -A--- State: ce. '. _Zip: <br /> C F2B <br /> Mailing Address (if different): 5.a_m_e___ <br /> City: -tiefState: LOC? Q 070 /� Zip: C <br /> Email: Ci h-e-Ve-C Q 0 1v Co tY) Phone:(AST zSZ- Z/gg <br /> Total Cost to Install Device (from contractor invoice): $ cQ`i --31,. 8 <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check directly from 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 authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> Signature of perty Owner Date <br />