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i <br /> � <br /> i <br /> � Backwater Prevention Device Rebate Program ; <br /> Vendor Payment Option Form ; <br /> Proj�c� Numbec _ _ _ (Gty to Provide) ' <br /> i <br /> Ptease complete both sides of the form ! <br /> Property Owner Section: � <br /> _ - ------ -- - -- -- _ __ -- --- -_ ' <br /> Piuperty Owner Name: _��L�' �� - �� ��-I --- ----..-- � <br /> �nslallalionAddress: . �3�_��� -- -- -- � <br /> City: _I�i✓�'��_ __ - state: . -�---Z'P- �I,�'2�� � <br /> _ - - i <br /> Mailing Address(i1 dillerenf): _ � <br /> ----_ _ _ _— _ _- -- -- <br /> i <br /> � City: _--- -_ _ State: -- Zip�- — ! <br /> Ernail: -- —._ _ Phonr.� ( ) . _ _ i <br /> Tulal Cosl �o Install Device (lrom contrrar.tar invoir.�J: 5 _ <br /> I, thr, prnpr.rty ownr.r, «:quesl to have Ihe City of�vereU[�ackwaler Prevention Device rebite r.her.k 1 <br /> for the inslallolion of Ihe devir.e at ihe abnv�referenr.ed property address be made payabie lo, and � <br /> senl lo, Rie vendor specdied on Ihr. back of this form Oy rr.questinr� the rebate cher.k hr. made � <br /> p,�yable to the v�ndor, I agrec to lhe foliowing <br /> I I�vill nol roceive � rebate check directly from the Cily uf Everett �, <br /> 2. Atisigniny paylm±id uf lhe tr�hatc to Ihe vr.ndnr does not excrnpl me Irom F3:+ckwalcr <br /> Prevenhon Device Rcba�c Pioyiam rcyuiremenls. <br /> __ i <br /> I �idhnnm the relr.ac��of my mbale lo ihi�vr.ndor listed on ih�� b�ir,k of ihis foim pendiny <br /> approval ot the<;ornpletr.d H��r.kv��ler Prr.vr,ntinn Devir.n rebate par.ke� hy �he City uf Fverr,l� <br /> I, ; <br /> � l'����, ���.�»� _ _ _ _ o�� ����-�__ � <br /> Siyn���ur�ol Proper�y Own�r n�lo � <br /> I _ __ _ - - _ _ _ -- - � <br />