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� Backwater Prevention Device Rebate Program <br /> Vendor Paym�nt Option Form <br /> Projecl Number _ (City to Provide) <br /> � Please complete both sides of the form <br /> Property Owner Section: <br /> Properly Owner Name:����/� �/cs J� L.�L• � • � <br /> Installalion Address oC 10��. vG�,�� l�u�1(�UC <br /> City:��f�12L.! T� � .State: l/V �' Zip:_��o�O� <br /> �vlailing Address(iI diHerent): _ -SI`�h1 L /9-S �B D vC <br /> City: __ Stale: Zip� _ <br /> EmaiL Phone: ( ) <br /> Total Cost�o Install Device (Irom contractor invoice). $��i C�U "� <br /> I —— — <br /> I, the property owner, requesl to have �he City of Everett Backwater Prevention �evice rebale check <br /> tor the installation of the device at lhe above referenced properly address be made payable to, and <br /> sent to, the vendor specified on lhe back of this (orrn. By requesting the rebate check be made <br /> payablc lo Ihe vendor, I agree to the following: <br /> 1. I �vill not receive a rebate check directly (rom the City o(Everelt. <br /> 7 Assigning paymeni ot Ihe rebate lo the vendor does not exempl me twm Backwater <br /> Prevenlion Device Rebate Program requirements. <br /> �- — ----- — - - - <br /> I aulhorize lhe release o(my rebate lo the vendor Gsted on the back of this form pendiny <br /> approval of the completed Backwaler Prevention Device rebate packel by the City of Everett <br /> . / <br /> / <br /> � GGy�,.._�, _���a --/s' <br /> — <br /> SignaWre of Property Owner Da�e <br />