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i_, ___ . ---------_ - - --_ _ __ _.___. ___ ; <br /> , , . <br /> } ����Backwater Prevention Device Rebate P�ogram <br /> � Vendor Payment Option Form <br /> � PrajeU Number. (City(o Provido) <br /> l i <br /> � Pleas� cnmplece both sides of the form <br /> t � <br /> � <br /> ! , Property Owner Sectlon: <br /> � <br /> � p Y �.Q� C'� 4, ��' U�t «�� �1��_ � � <br /> Pro ert Ownei Name: <br /> } In5lellationAddress� I �� �- C�. ���\n�/ (�� <br /> � Gty:��•�' �� Stato; l{-�'T' Zip: �7 'J c�L ( 1 <br /> � — , <br /> I <br /> , hlaliinp AdCress (i!dlHere�1J: � <br /> I /� . <br /> � �ih,. `�.�E ( `C Stole: 1�Zip: � �7�� � <br /> � Eman: �eb� irrc � 6(�k (� C� ��'Pn��:�c{ � S �Sc L4� ( � <br /> 'L t,' �`' <br /> � Total Cost to InStall De��ice (/rom conVaclorinvoicej: S�� � <br /> � <br /> � I,tha property owne�, request lo have Iho City of Everetl Backvmler Prevention Devlce rebate check <br /> lor Ihe installation of Ihe device at the abova referenced property address be made payab(e to, and <br /> � sent to, �he vendor speclfietl on lhe badc of thls iorm. By requesting Ihe rebate check be mada <br /> poyaWr. to Ihe vendor, I ngrce to Ihe following: <br /> ' 1. I wlll not recnive a inbala clteck diroct�y from Iha City of Evnrell. <br /> 2. Assiguiny payment of lhu rubetu lv Ow v�ndor Jous nol exmnpl mu frmn Backwalai <br /> Prevantion Devica Robnlo Progrnm requiremenls, � <br /> I aulhorize lhe relueso 01 my tebale lo Ihe vunda Ilsted wi Uw back ot Ihis furrn pnnding <br /> • ppprovpl of tha completed Buckwnler Prevenlion I"levice rebate pacVet by Ihn Clly of Fverott , <br /> � <br /> /) � <br /> ' . ��� ���' � . , T1� ' I <br /> �- - <br /> , <br /> Signature of Proparty Owner pote <br /> � <br /> • i <br /> � <br /> �----'— --- - ------------ -'-- — --- - .� _ .'�------- - --- I <br />