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Backwater Prevention Dev' <br /> ice <br /> E� Reb��te F'rogram <br /> F�r intemal Use: Project Number <br /> Vendor Pa��ment Option Form <br /> Please complete both sideslof the form <br /> Property Owner Section (please print): <br /> --- ----___ , <br /> � r: �ih�.r-----,-�.�.�Nc_( — — - -- <br /> - - -- — <br /> �\ - -, <br /> ��:��_� � (.,u � �. � �- - <br /> [F;roperty OvmerName) I — -------�— <br /> -L_, /� �_. ,��,� <br /> r <br /> `��"�=�-`�c1=�-- !�\J�-�F--=�',�'' ---� `-�,'_—�E'---�1 - <br /> (Prnpeity'�Addra,s^? �Git)� �State3 (Zipi� - <br /> — - —--- - -- — ---- __---------- <br /> rAlte.'rn`afe Mailmg'Add�ess Cily� j State' �7 �'� <br /> �—_, <br /> _`�•�Z�)__`Z.�fj�_-- C nr.)�CC "' _�^^��Lcr`^— <br /> Phone Errioil <br /> �_:� L..,__� <br /> —___-- --- ----------------- -- .— <br /> I, the Propr:rty Owner, reyuest b have the Cily of Fve,retl Bar.kwater Prevenlion Device <br /> rebate check for ihe installation referenr.ed at the Pronerty Address be rnade payable <br /> lo, and sent to, lhe V�ndor. Ry requesGng the incentive/rebate check he made payable <br /> to the Vendor, I agree to the followinc� ' <br /> 1. I ��,�ill not receive a enr.kwater Prevention Device reba(e check directly from the <br /> Ci�y of FvereU, <br /> "l Assigninr� paymenl of the E3ackvdater f'revention Device iehate to the Vendnr <br /> rloes not exempl me frorn [3,ickwulei PrE�vent�on Dt�wr.c flebate Progr;tm <br /> requirements: , <br /> I �julhori:e ihe ielease of nty rr:ba�e to fltC Vendor listed on paye two of this form <br /> pending approval of tfie cumpleted B;ickwater f'reveiition I)evic.e reh�te par.k�ge by <br /> ihe City o( Fverett-�'' <br /> � <br /> � <br /> _ _ _. � .��=�---- -.-- --�Mn�_�V��VI� <br /> _�yn��h�rn. oll'roperty Owne� (D:if� <br /> ,������ <br /> Rewsed 9!1;2014 Page 1 0l 2 <br />