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i <br /> i <br /> Backwater Prevention Device Rebate Program � <br /> Vendor Payment Option Form j <br /> � <br /> Project Number (C�ry ro Provide) � <br /> �` <br /> I <br /> Please �oi7iplete boii� sicles of the form <br /> Property Owner Section: j <br /> — - -- -- -------------- � 4 <br /> i + <br /> � PropeAy Owner Name: �L_�i C i <br /> ! Installation Address' __�� �o.�P( 19(�P � <br /> CiIY' �(�-r'� Slate �_ Z�p: 90 u�0 ( � <br /> � MailingAdtlress(ifdll/erenf) J��- �c �C( aJ�• __ � <br /> i I L n p <br /> I City �iL)C� (QrT State: �.!/i^! 2ip. 90�� � _ � <br /> i Email �c�o 5�.2 CP1 �FGcviO • G0�,4_ Phone (y2� �Sa-6 6 y7 ' + <br /> � Total Cost to Install Devfce (Irom con�racrormvoiceJ S � <br /> � <br /> -- ---- --- - — � <br /> I. the property owner, request to have the Cdy of Everell Backwater Prevention Device rebate check <br /> (or lhe inslallation of the device at the above reterenced property address be made payable to. and <br /> sent to. lhe ventlor specified on the back of Ihis foim By requesting the rebate check be made <br /> payable lo the vendor, I agree lo the following: <br /> 1 I will not receivB a rebate check duecdy from lhe Cily of Everelt <br /> 2 Assigning payment of the rebale lo the vendor does nol exempt me from Backwaler � <br /> PrevenUon Device Rebale Progrem requiremenls � <br /> _ --� _ — .--- -- � <br /> II aulhorize the retease of my rebate to the ventlor Gsted on the back ol lhis form pending I j <br /> approval of the compleled Backwaler Prevention Dewce rebate packet by the City ot Everett � <br /> � i <br /> I � <br /> i <br /> �/I.t.C.�i .��/3 ���~ 1 <br /> i i <br /> � Signature o Property Owner Date } <br /> i <br /> ----- - — ---------- ----— -- i <br /> I <br /> � <br /> � <br /> i <br />