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! <br /> � <br /> � Backwater Prevention Device Rebate Program ( <br /> � Vendor Payment-Option:Form '_, ( <br /> �. , <br /> � <br /> � Pro�ec:Numbec -- ' _'(City'to ProJide) �" ."` „'' i <br /> .. . — . . - . ... j <br /> � <br /> Please:complete bothsides of the form ; ♦�' ± <br /> � <br /> ,. . � <br /> _ ; <br /> `Property:OwnerSection�: l I <br /> �`� �'� � I <br /> Property Owner Name: VY�Y W'. `` - ' <br /> Instatlation ACdress: S �1�"1 <br /> i ���Y —1L��LIZh� Sta(e: ..�_Zip:�i�✓, ; <br /> . ; - . . -.. � . . . . . j i <br /> ' Mailing Address(iPdiHerent)c i � <br /> City: State� Zip:_ I ! <br /> � 1,,, ;��,/ � <br /> M,�,,n" g� • ieN� ; <br /> Email: . ���%(�� (V� -�7-��d�y,vil,�,� Phone {�Q) j <br /> Total Cost lo Inslall Device (/rom contrac(or rnvorceJ: $._��ScG_ �� � <br /> . ` , , � <br /> . � � <br /> - -' <br /> I, the property owner, request.to have the Cily of Everett;BackwatecPrevention Dewce rebate�check` � <br /> for the installation of'the device at�tie above referenced property.address be made payable to and " � <br /> sent to, the vendor.specified on 18e.back of:this form .B.y requesting',the rebate,check be,made , ., , ; <br /> , - � <br /> �payabie to the vendor; I agree to:lhe followiny. ' � ' � " � <br /> 1 I�vill not receive a rebate check duectly from the City o(Everett ' <br /> 2 Assigning:payment ofthe.rebate to the.vendor does not;exempt.me from Backwater { <br /> Prevention Deyice Rebate Program ieqwrements 4 <br /> I authonze the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater.Prevenlion Device re6ate packet by the City oEEverett i <br /> � � . . . . _. . . . �.. � ' � i <br /> _ . . . . . . � �, <br /> 1 <br /> c��+�� ��h• /�� i <br /> � <br /> i atureohRroperty,Owner ; Date � <br /> i <br /> i <br /> i <br /> ; <br />