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„ gin, <br /> e a” <br /> L' Backwater`Prevention Device Rebate Program <br /> z� <br /> 6a <br /> rl 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: - <br /> ,,::),_61 ;(..:c,,I.)4-Lt 0 6:1 it(t--6\P6---‘5fl-lvt-v'----- l'ijr <br /> Installation Address: <br /> t:,--Z <br /> City: � <br /> , , + State: Zip: � :t' b <br /> ailing Address(if different): <br /> City: State: Zip: „41;,;"--;04,;,, `' <br /> mail: Phone: ( ) i <br /> I Cost to Install Device(from contractor invoice): $ <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 bea 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 /> y, <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 /> I <br /> V <br /> Signature of Pviperty Owner Date <br /> r,. ..... . . . . .... .., ,.F, . ,,x ,� � : /,wA'wd .s . fi7 . . $.t. 3r a ,a_-<n„S <br />