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� <br />Backwater Prevention Device Reb��te Prugram <br />�: Vendor Payment O�tion F��rm <br />Project Numher. __ _ (City to Provide) <br />PlPase complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Installalion Address� �� � 3 � _ ( %r Pt� � ,'c �.�/ <� _ <br />'1 .J <br />City: `1—�-'�z p- Slate: �/IL Zip: %�'a-=� <br />Mailing Address (i! diflerenQ: <br />City: Slalc: <br />Email:_.,]`-r�' 1t?�"� �� c��r�..�J.�� Phone: (`�,���"3 �`/ 5c713 _ <br />•�K� <br />Tolal Cosl lo Install Device (lrom can7actorinvoice): 5� �� "—'� <br />I, Ihe properry ov✓ner, requesl to have the Cily of Everetl f3ackwater Prevenlion Device rebale check <br />(or thr, inslallalion of the devir,e at the above referenced property address be made payablc lo, and <br />sent In, the vendor specdied on the back of this fonn. f3y requeslin� Ihe rebate cher.k be madr, <br />payablc lo the vendor, I agrce to the following: <br />7. I v�ill not receivr. a rehate check chrecUy (rom the City ol Everell. <br />2 A,signing payment oi tlic rebote lo the vendnr docs nol er,empl rne fram ��ick�vater <br />Prevenlion Uevice Rebalc Prayram rcyuiremen�s. <br />I aulhnnre lhc ielease of my rebate lo O�e vmidor lisled on Ihe back o( ihis fonn pendinc� <br />approval of �he compleled Backwaler Prevention Uevice rebate packet by lhe Cily of Everell <br />� ' �) <br />-- �--- <br />Dale <br />