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i <br /> � <br /> I <br /> i <br /> � BackMrater Prevention Device Rebate Prograr� ' <br /> �w e�� Vendor Payment Option Form <br /> I <br /> � <br /> Pro;ect Number T (CJIy fo P�ovitleJ � <br /> � <br /> Fiease compiete bof�i sides oi fi�e form � <br /> Property Owner Section: � <br /> I <br /> _. ..—_ _. i <br /> �� �, <br /> Property Owner Name: ���, ���D� J� � <br /> i <br /> Installetion Atldress _��� �C��,� V <br /> r •, _7_ I . <br /> i ��ry����!'c�b'7 s�ate:__l.�/_�_iip:�Q/ � �6�C� •; <br /> i <br /> iMailing Atldress(IfdiKerent):� � i I <br /> C��Y�l.., SSetet Zip: <br /> I ! <br /> i Email', Phone; ( ) ; <br /> ITotal Cost to lnstall Dev�ce(Irom contrsc(O�invoice):3 � ; <br /> �------ ---� --._ l � <br /> , <br /> I, the prope�ty owner, request to have th= C�ty of Everett Backvaa(er Prevention Oevice mbate check � <br /> for the inslallaiion of the device at lhe above referencetl property address be made payab�e to.and ; <br /> sent to, the vendor specifed o�the back oi Ihis form. By requesting the rebale check be made ; <br /> payable to the vendor. I agre2 to the fotlowing: ; <br /> i <br /> 1. I wifl not receive a rebeta check diredly from the City of Everetl � <br /> 2. Asslgning payment of tlte rebate to ihe vendor does not exempt me from BBckwaler <br /> Prevention Device P.ebale Program requiremenls, � <br /> II i aulhorize the retoase M my rebate to the vendor N�led on the back oi this form pentling � <br /> approvel of the compleletl Backwater Preventton Oevice rebate packef py t�e Clty of EvereH � <br /> � � <br /> I I <br /> _ _ �i,��Qi a0��l ! <br /> , <br /> Signature ol roperly O�vner ' Date � ; <br /> I <br /> --____------- - _---___ __._._ - . �- -' i <br /> . �. <br /> ; <br /> � <br />