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, � <br /> / Backwater Prevention Device Rebate �rogram � <br /> �~�?� Vendor Payment Option �orm ; <br />� � Pro;ect Numbec __ (Cify lo Pr�vioo) <br /> Please complete both sides of the form j <br /> I <br /> Property Owner Section�—^ — - — — � <br /> f'mperty Owner Name: _ ..1��m0�'�,_ �jfttYy�t"'(1L� 1 �1�-� i <br /> Installation Address _z3�_�__�ro7�fi:�__�` ���� • � <br /> (:i�y: ��� --State. ��--/-�Z��p'—J" 2O/ � <br /> Mailing Address(ildifle�entf: 2��� �L�( Pi� �1/� - I <br /> Ciry: ��. --- State: _(/1/1`7 Zlp��d � � <br /> Gnail: �Q,rnanUl���s��Phone: �_��_v� / IO � <br /> Total Cost to Ins�all Devicc (1mm r.onfnr.tor invo`crg$���"g6__ _._ ____ <br /> I <br /> _ ( <br /> � <br /> �, the property owner, request to have the City ot Fverett Backwater Prevention Devir.e rebate check � <br /> for the insfallation oi the device el the ahovc refcrenced ptopeAy addiess be made payable to, and � <br /> sent to,the vendor specified on Ihe back of this form. By requesting the rebate cher.k be madA I <br /> payable to thn vendor, I agree to �he followinq: <br /> 1 I will not rer.eive a rebate check directly from the City ot Gvorefl. i <br /> 2 Assigning payment of thP rebafe to the vendor does not exempl me(rom f3ackwatr.r I <br /> Prevention Device Rebale f'rogr�m reqwremenis. <br /> --. _ _ _. _ --- _ ..._ _ __ _ --- ---------- j <br /> I authon�c Ihc rel�asc ol my rebete lo Ihe vendor listed on the hack of this (urrn pending � I <br /> approval o(the complcled Backwatcr Nrevention Uevice rebale packet by the City o( Fverett � <br /> i <br /> I <br /> y��-15--- , <br /> nalure o opert Own . / De�e I <br /> I <br /> — -- -- _ ------ ----- -- - -- — — --- � <br /> i <br /> � <br /> � <br /> � ( <br /> 1 <br />