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Backwater Prevention Device Rebate Program <br /> F Vendor Payment Option Form <br /> � <br /> Projec Numbe! ___ — _ (Gty to ProvideJ <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> ,-- -- 1 ,, , <br /> - --- <br /> — --- — - — � <br /> Property O�•mer Name -" <br /> I I 1 (YA _St11 _ ____._. <br /> �_�1-- ---- I <br /> � Installalion Address'�_���.�.i-�-��Q—-- - - <br /> � Cdy _��L�ti�L'�-� — - State: —���Z'� - —►�''� L------ I <br /> IMailing Address (ifdiKerent)' — -- — -- — I <br /> State _ Z'P�_ - —-- <br /> IC�ty ---- — - — __ — <br /> [mail: _r���l� '`O .�C�C�1'�3��-��—_ _ Phone (�L���l�.n_ 1;3`I�- <br /> �� , , <br /> � ��� �s'�— -- - <br /> I Total Cost tu InsWll Device (Ircri contrar.ror mvoir.e 5 __ � <br /> � — ---- -- --- — - — — — - -- — <br /> I, the property owner, reyuest lo have the City of L•verefl Dackwatr.r Prevention DevP�rebate check <br /> sent tolrthe Ivendo�speafied on tf1iehback of th s(form. Fiy�r��i sting ihesrebale cher.k3be i���e ,nd <br /> payabie tn the vendor, I agree to the followl�g <br /> 1 I wdl nol recuive a rebate check direr.Uy from Ihe City of Fveretl. <br /> 2 Ass�ynmg payment of lhe rebale tn Ihe vendor does not esempt me from E3ackw,dcr <br /> Prevention Device Rebate Prngran� reqwrcinents <br /> I aulhorim the release ol my rebate to the venAor I�sled on lhc back of�his lorm pendiny I <br /> approval ol the compleled Bar.kwater PreveNion Device rebate packe! by R'e Cily u( Everett <br /> � � <br /> � � �.��___���__,�,�,�-�.=.1-- f_ ��/��- - - <br /> i a�� <br /> � Siynature of Prr,perty Owner � <br /> — --- - , <br /> � <br /> � _— - - - - - — --- - - -- — — _ <br />