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i <br /> i <br /> ; <br /> � Backwater Prevention Device Rebate Program ' <br /> Vendor Payment Option Form ; <br /> � <br /> ! <br /> Project Number _ . _(City fo Provide) � <br /> � <br /> ( <br /> Please com�lete both sides of the form � <br /> Property Owner Section: j <br /> f <br /> ( _ �. _ –- ; – --- --r- — — — — ; <br /> Prnperly Owner Name �_`� o ,i'—� `'' .''>-�o- `=1— --- 1 <br /> n r / I <br /> ' Installahon �ddress: '' ;_=�'S��-� L.> v �<�r:� �" _ _— I � <br /> Ciry: ,�,'✓�� L � i y _Slate l�`- Zip_�� ���� i I <br /> � <br /> Mading Address (ildd/erontJ. _ _ __ ___ - 1 <br /> I <br /> ' City: c�'vy .c � 7 � -- Stale _ ��� Zip_ . � � `�� � � <br /> _ , <br /> EmaIP — — Phnne (d1s��S L �c/'/� I <br /> Total Cost to Install Devicc (Irom conlrar,Mr invoice) b r x�`��� � — I <br /> i <br /> � _— _ -- -- - - -- - — -- I <br /> I lhe propeiiy owner, requesl to have Ihe City of Fverell Hackwater Prevenlinn Uevice rehate cher.k I <br /> (or Ihe installahon of Ric devir.e al ihe abovc rcicrenced property address be made payablc to, and i <br /> senl lo, Ihe vendor specitied on Ihe back of this form By requestinc�the rnbate check be maAe <br /> payeble to the vendor, I agree lo Ihe followmy � <br /> 1 I wdl nol receive a rebato r.hr.ck directly Irom the CAy of Everett j <br /> ! <br /> 2 Assi�ning payment ol thn rebale to the vendor does not exemp� me(rnm 13ackwater I <br /> Prevenlion Dr.vic� Rehate Program rr.quuements , <br /> - - ' <br /> I rauthonzc Ihe release of my reb�tc lo Ihe vendor 6sted on Ihe back of Rns torm pendmg I <br /> approval ol the completed Rackv�ater I�revention Oewr,e rebate packel by the City nf Cverett i <br /> I , <br /> 1 J <br /> I( i <br /> � . / _ ' - . . \ _ � '�, <br /> J_i� �r__ -1 �. � I �� J � <br /> � j' <br /> Sic�nature of Propr,rty Owner ���e , <br /> � <br /> I <br /> i <br /> i <br />