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i <br /> Backwater Prevention Device Rebate Program <br /> Vendor Qayment Option Form <br /> Projecl Number. __ _ (City fo Provide) <br /> Please complete both sides nf the form <br /> Property Owner Section: <br /> Property Owner Name: _�-���__LY�V`'_� �v V____ I <br /> � �' � <br /> Installation Address:����• __ _ � <br /> Cily:�I/1�� State:�.A�"� _Zip: ta `'"� 3 I <br /> Nlailing Address (ildiKerenf): ___ —__—_ <br /> City: _ State: __ _ Zi <br /> P: ------- <br /> Email: ____ Phone:'�l� )�S�-yB�� I <br /> �/ 3� i <br /> Tota� Cosl to Install Device (Irom r.ontractor invoice)' $__��� / _____ . ____ ! <br /> � - I <br /> I, the property owner, requast to have the City o(Everett Backwater Prevention Oevice rebate check <br /> for the installalion of the device al the above referenced properiy address be matle payable to, and <br /> sent to, the vendor specified on lhe back oF this torm. By requesting lhe rebate check 6e made <br /> payable to the vendor, I agree to Ihe following: <br /> 1. I �vill not receive a rebate check directly from the City of EveretL ' <br /> 2. Assigning payment of lhe rebate to the vendor does not exempl me from Backwater I <br /> Prevention Device Rebate Program requirements. I <br /> I aulhorize Ihe release of my rehate to the vendor lisled on the back of this form pending I � <br /> approval of the compleled Backwater Prevenlion Device rebate ��acket by the City of[verett I <br /> i <br /> � <br /> �1�� ��«/�-�-t C:• - �.1�� � <br /> Signature of Property Owner Date <br />