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. _ _ .. _ . . � - -- - <br /> _ ._ . . _ . . . . <br /> .�-- ��.. -- : <br /> � Backwater Prevention Device Rebate Program <br /> � � Vendor Payment Option Form '. <br /> s <br /> Project Numbar. (Citylo ProvideJ � . <br /> ` <br /> ' � Please complete both sides of the form � <br /> � <br /> Property Owner Section: <br /> , ' � <br /> 1 J /�, <br /> Properly Owner Neme: 5 � ��i C �`���' KQ�•� ` ''1`�`s�1��- � � <br /> Inslallalion Address: �3 S �Q i!1 G F_ r,J� <br /> ' Ciry:�✓Q.�G�r1 State� Ii✓a z�P: 9�a� � <br /> , � <br /> Mailing Aadress(i(dltierent):__ � <br /> � Ciry: State: Z�P� . <br /> i Email: (o� l' e w �it��4'-�^'SJ1—Cn••n Phone:(}uQ •7i 3-0 7�6 <br /> r <br /> Total Cost to Inslall Device(Irom contraciorinvoite):5--�7Lk�.� . <br /> � I,the property owner,requesl lo have the Gry of Everelt Backwater Prevenlion Device rahale check <br /> � tor the installation of Ihe device at Ihe above referenced property address be made pnyable to,and <br /> sent to,the vendor specified on Uie back of lhis tortn. By requesling the rebale check he made <br /> pnyahle to 1he vandor, I agree lo lhe(oliowing: � <br /> i 1. I will not raceive a rebate check direcliy trom the City of Everett. <br /> 2. Assigning paymcnl of Ihe rebate lo lho vendor daes nol exempt me trom Backwalor ; <br /> Prevenlion Dovice Rebate Program requirements. <br /> I aulhorize Ihe releaso ot my re�ale lo lhe vendor lisled on the back ol this(orm penAing <br /> approval of the completed Bar.kwater Pr�vention Device rebate packet by the Cily of Everelt <br /> � ' <br /> I <br /> ; J� � /l •�-• G- �. a� is ; <br /> 1 Signature�erty Owner Dale I <br /> I <br /> � I <br /> { I <br /> 1 <br /> � <br /> ( " ' .._ ... .. . . " " .._ . . . .. .. ._ .. _. .. -... • <br />