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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (City to ProvideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Ou�ner Name: M� �l <br />InslallafonAddress: ��13U <br />� City: <br />'!, Mailing Address (il diNerent): <br />City: <br />Emaii: <br />-+e� c.ss�� <br />V��Ln���. E <br />1— <br />State: <br />Sl2te: <br />Total Cost to Install Device (f�m contractor invoice): S <br />_ Zip: <br />_ Phone: ( ) <br />�rU�: c�a <br />/ � <br />.:, <br />I, tne propedy o�vner, requesl to have the Cily of Everr.H Bar.k�vater Prevenaon Devir.c: rebnte check <br />for lhe i�stallation oF the device at Ihc above referenced property address be made payable to, and <br />sert to, ihe vendor speci6ed on the back of Ihis form. By requesting lhe rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebate checl; directly from the City of Everett. <br />2. Assigning payment of lhe rebate lo the vendor does nol exempt me irom Backwater <br />Prevention Device Rebatc Pmgram requiremenls. <br />I I authorize lhe retease of my rebate to the vendor listed on the back of Ihis form pending <br />approval ot the completeA Back�vater Prevr.nlion Device rebate packet by the Ciry oF Everett <br />I � � n r/� - _ <br />� � .___ ' '���G/1 �1�f/ �� �% ` � 5 _ <br />Signalure of P perty Ovmer Oate <br />