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i <br /> � <br /> Backwater Prevention Device Rebate Program � <br /> � Vendor Payment Option Form ' <br /> i <br /> Pro;er.t Ncmber (Cily fo Pio�ide) ( <br /> I <br /> Please complete both sides of the form i <br /> Property Owner Section: � <br /> - -- � <br /> I, Prooerty O�vner Name: �� �.�.r�_ • I <br /> I Installation Acdress: Y �Z LO� �\ � ___ � <br /> I Ciry: ��� Slal��J� Zip: ��Z O� ; <br /> IMailing Address(ildiNerent): ` <br /> ! City: Stale: 2�p: � <br /> i <br /> Email: Phone: (2-�' ��� 2�C� � j <br /> I <br /> Tolal Cost to Install Device(from contracfor invoice):5� ,Scc.� � ! <br /> ' I F <br /> ' - I � <br /> i,the property owner, mquest to have the City of Everetl Backwaler Prevenlion Device rebate check ' <br /> for lhc installation of the device at the above referenced property address be madr. payab!e to,and � <br /> ,enl lo,it�e vendor specified on the back ot Ihis fonn. 9y requesUng Uie rebate check be mode <br /> payable to lhe vendor, I agree lo lhe fotlowing: 1 <br /> f <br /> 1. I w�ll not receive a rebalo check directly irom the City ot EverelL I <br /> 2. Assic��in�paymenl of the rebate to Ihe vendor does nol exem�t mo from Backwater � <br /> Prevenlion Device Rebale Program requirements. ! <br /> f <br /> I aulhorizo Ihe relca,e of my rebate to the vendor iisted on the back o(this(orm pending I <br /> approval of the cnmpleled Backwater Prevention Device rebale packet by the City oi[verett <br /> I <br /> i <br /> � �� ' 3--17� -- !s i <br /> — _ � <br /> Signature of Praperty O'wa Dale ' <br /> j <br /> -- - — -- � <br /> i <br /> I <br /> ! <br /> I <br /> � <br />