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Backwater Prevention Devic:e Rebate Program <br /> Vendor Payment Option Fo,rm <br /> Projec.' Number. (City to Provide) <br /> 1 <br /> Please complete both sides of the form <br /> Property Owner Section; <br /> I Property Owner Name:��} N �� /v�h�4 I u✓�C L�-�-' _ <br /> Installation Address: _�.?�OCretE��e�' /TV� '-I��/�.�'_T � <br /> City' �.lJ2��� Staie: �.l�A Zip: qg z� � _ <br /> hiailing Address (if differanf): �� ��4 �(.��P1' ' �C11 Fi <br /> ciry� CUC�� state: I.t�A z�p: �8 203 <br /> Email: ��ar��i� sa� � ��ahoo.eor►� Pnone: (<}L9 �(�D-b2.`�D(CCI� <br /> qis -3j� -�9�— <br /> Tolal Cost lo Install Device (from contractorinvoice): 5 <br /> I, the property owner, requesl to have ihe City of Everett Backwater Prevention Device rebate check <br /> for the installalion of the device at the above referenced property address be made payable ro. and <br /> sent to, the vendor specified on the back ot this form. By requesting the rebate check be made <br /> payable to the vendar, I �gree lo tlie following: <br /> t. I will not receive a rebate check directly fron� Ihe City of Everetl. <br /> 'L. Assigning payment of the rebate to the vendor docs not exempt me from Backv�ater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize lhe release of my rebate lo the vendor listed on the back oi this form pending <br /> approval of the completed Backvoaler Prevention Device rebate packel bq the City of Everelt <br /> ) . ��{,� 5 �o��i5 <br /> � <br /> Sig� ature of Property O�vner Date <br />