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i <br /> � <br /> � <br /> [3ackwater Prevention Device Rebate Program f <br /> Vendor Payment Option Form � <br /> Project Numbe�c ________ __. (Ciry to ProvideJ � <br /> � <br /> t <br /> Please complete both sides of the form � <br /> I <br /> t <br /> Property Owner Section: i <br /> � <br /> S / - � _--- __---- i <br /> Property Owner Name:�L,�__ �`+ � �t- ��UY <br /> InstallationAddress:_�_I ,�-7 CGGL/ �d' _ _ ' <br /> City: (,✓Y-/��_--State. ��� _ Zi i �Lv � � <br /> P'---- <br /> Mailing Address(il dillerenQ:_�_ ___ ______ _ � <br /> City: _- _ _ _ Stata: _Zip� _i i <br /> i <br /> Emaie _ ------- ------ - anon« ('11i) 2�v `�ySI ; <br /> Total Cost to Install Device (liom confractor invofce): $ _ _ .____ i <br /> i <br /> _ _ --- � <br /> I, the property owner, requcsl to have ihe City o(Everett R�r.kw�ler Prevenlion Devir.e rebate check } <br /> for thc installalion of the device et the above referenced property address he made payable to, and j <br /> sent lq the vendor specif ed on the back of ihis form. By requeslinp !he rebale check be made � <br /> rayable to Ihe vendor, I agree to Ihe following: � <br /> 1 I will nnl rer,eive a rebate check direcUy from Ihe Cdy of Evereli. ' <br /> i <br /> 7 Assiynin9 paymenl ol Ihe rebate I��ihe vendnr does not exempl me from Backwa�er � <br /> Prevention Device Re6ate Program rcquironicnts <br /> — --- -- -- _ . ._ . _— <br /> � <br /> I autnori[c lhc rcicase of my reUate to Ihe vendor lisled on the back ol Ihis form penJing � <br /> approv�l ot lhe r.ompleted f3:�r,kwaler Prevenlion Devicr. reh�de puckel by thr. City of Gveretl � <br /> � <br /> I ; <br /> .� � nc� �c�- _1�. — �15 __ , <br /> � <br /> Slgnatwe i Property Ownor Date <br /> � <br /> i <br />