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Backwrater Preventiur. <br />Project Numbec _ <br />Payment aption <br />(Ciry to ProvldeJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: Gt,avf • c R. �Dz(�x i 1 _ _ <br />City: _E�c.-�� State: u%� Zip: y� �� <br />MailingAddress(i/different): �q'tc'3 --i)u�� PI w _ <br />City: L��w�ud _ State: I.�P _Zip: 960:�(� <br />Email: ol.,osc{ebelf � ao�_cew� Phone:(aJ„) q�`t-`r15� <br />Total Cost to Install Device (Irom contraclorinvoiceJ: 5 <br />I, the property owner, request to have lhe City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above re(erenced propeAy address be 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 />I will not receive a rebate check directly from the City of Everett. <br />Assigning payment of the rebate lo the vendor does not exempt me from 8ack�.a�ater <br />Prevention Device Rebate Program requirements. <br />I authorize thc release of my rebate to the vendor lisled on the back of this form pending <br />approval of ihe compleled Backwaler Prevenlion Device rebate packet by ihe City of Everett <br />� '� 5- I - I S <br />Signature of Prope�0 Date <br />