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-- • ------ --- -- •- • _ . - - -- . . _. i <br /> _ � <br /> ... Backwater Prevention Device Rebate Program I <br /> � Vendor Payment Option Form I <br /> I � <br /> ? � Projed Number. (Crty to Provide) i <br /> � <br /> i �' Please complete both sides of the form � <br /> � { <br /> ` Property Owner Section: <br /> I <br /> Property Owr,ar Name: , 3't4"t��/l.. i/}'�P�'l �SC��'l � <br /> I ^ ,,, 1 <br /> ' Installation Address:�C1 ��_���� . � <br /> � _ . � <br /> � ciry: �C� h°�M State:��_Z�p: ��� � <br /> � Mailing Address(i/diNerenQ: ' <br /> ... Ciry: Stele: 2ip: <br /> Email: (�C44'GI�SIOI�� 1'V7(YYYi.� .('[S1fYlPhone:(qaQ .�Sg— I��d <br /> Total Cost lo Install Device(from contracfor invoke):5 ���J�J� • �� <br /> � I,the property owner,requesl to have the City o(Everetl Backwater Prevan6on Device rebale check ; <br /> for the installation of the device at t�e above re(erenced property address be made payable to,and <br /> sent to,the vendor speGfied on Ihe back oi Mis tortn.By requesfing the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebale check direclly hom Me City ot Everetl. <br /> 2. Assigning peyment of the rebete lo Ihe vandor does nol exempt mo from Backwator i <br /> _ Prevention Device Rebate Program requirements. <br /> .. � � <br /> I authorize the release o(my rebate lo the vendor listed on lhe back of this form pending <br /> approval of the completed Backwaler Prevenlion Device rebate packe[by lha Ciry o1 Everett <br /> � <br /> 5 <br /> Signature of Propert , wner te <br /> . � <br /> .. ... I <br />