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Backwater Prevention DevicEa <br /> Fy Rebate Program � <br /> � <br /> For internal Use: Project Nurnhe� � <br /> Venr�or Payment Optiion Form � <br /> Plcasc compl�te both sides of tha torm ' <br /> i <br /> Property Owner Section (please print): <br /> - - •--- - ------- /_ x R;_= c', � ',� � <br /> -- ` c7--� _ � - /�?J %�Oc�'(� ! <br /> F> :A7�=_ or ��/�/'_c��. 7/ o�L.�.=d._--- - - �� 'c� <br /> , Prnperly Owr,e� Namc �� r. <:-= ,` � <br /> � �11-u__ �!1_ic�:� -- �_- �.,C��/�_ `i���_i 3_ i <br /> Praputy Addres; C�ty� State Zip (- <br /> , � �'� �-._- �--�-`f'�!f��----�•�'!-�w�7Lr.��,_ CPI� . ltJ 2 >U , <br /> ��� - 7 --. __----- . <br /> ' Al;ernate 69�uimy Addrt;ss City State Zip <br /> yZs • 3 �� � - �Y� � <br /> -- ----- -- — --. _- ----- ---- - - <br /> r honc � Emad <br /> � — - ---.._ _ _- - - _ _ _-- -- -- - - - -- --- - <br /> I, the f'roperty Owner, requesl to h:rvc� thre Cily e( Cverett f���ck�vater F'rcvei�hon Device <br /> rebat�; check (or ihe instali;�tinn ref��renced �il the Property Address be made payable � <br /> tu, >�nd senl to, the Vendor Ely reryuesting the inr.entivehehale cher.k he made payahle <br /> tu ihe V��ndor, I �grcr_ to Ih� follutving: ' <br /> 1 I vdill not receiv�� .i t3ock�vatnr Frnvi�nli�m f�evicC reb�le cher.k dir�;c�ly from the � <br /> City of f:verell � <br /> 2 llssiyninq payrnent nf the Ci�ickvriter f'ievr�niton Uevice reb,.ite to the Vendor ' <br /> dons not ��x��nipt tn� (rom ki,�r,k�v,il�r f'revi�nt.on f)evir.e fteh,�te Prc�gram , <br /> iequirenicnis <br /> I aulliunte the i�let�e,�� o( niy ieh�t�� !�� Ih�, Vendui hs�erl nn pa�7r� hvn u1 Ihis fotm <br /> E�endiny approvul o! �h<; r.�nnp�ele;i I_n� kwat��i ��icv�rnh<m l)evic�: iotiale packagu by , <br /> lli�� City n� Cverclt <br /> � <br /> _�'� c�---- - � ��-�-s -- � <br /> 4ignatura nll'ropo�ly ns�ncr Dnln . <br /> �'ayn 1 �(2 ! <br /> ReviseA 9l3!2014 . <br />