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i <br /> , <br /> �^� Backwater Prevention Device Rebate Program i <br /> ' Vendor Payment Option Form <br /> Projed Numbc'� .-_.-- V(Cdy Ic PraviCr.) � <br /> Please compleic boiii sides o�tne'form <br /> Property Owner Section: <br /> PiopertyC�,rnerName: l��o-'(� \C'� ��11(`Ae55 <br /> IInstallationAddress �Zb C_o\1��_j��fL_. <br /> Ci,y:�jLCCt C� State:_ W��_Zip: �Q"i 2� � • <br /> � <br /> !�talling Address(ifCifterent): <br /> City: Stat�: 2ip: <br /> [mail� � � . �Uc�_S��oL.�( • Lo� phone:(�Vz�S G9\-o6°,9 <br /> � Total Cost to Insta!I D�+vice(from con6actorinvoiceJ:5 <br /> � <br /> I,lhc property oK�ner,requost to have lhe City of Everett Backwaler Frevenlion Oevice rebate check i <br /> `or the installation of Ihe device at fhe above referenced property address be made payable to,and I <br /> sent tn,Uie vendcr spedfed on the Lack of this form.By�equesting the rebale check be made <br /> payabl:;o tt;e vendor, I agree lo the following: , <br /> 1 1 e:ill not receive a rebale check directiy from the City of Everett. � <br /> ?, Assiyning paymenl of!he rebalc to Ihe vendor does not ezempt me from Beclnvaler <br /> Prevention Device Rn�ato Picgram reqmrements. <br /> _.. _ — i <br /> I authorize lhe release of my rebate lo Ihe vendor listed on the back of this form pentllny � <br /> approvat of the completed f3ackwater Prevenllon Device iebate packet by lhe Cdy of EvercU . <br /> � J _�Z 5 I � <br /> Signa ure 1 Propen vme Date , <br /> � <br />