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i <br /> ; <br /> , <br /> � <br /> � Backwater Prevention Device Rebate Program ' <br /> Vendor Payment Option Form <br /> i <br /> Projed Number. (Ciry to Provide) ` <br /> , <br /> i <br /> Please complete both sides of the form <br /> Property Owner Section: I <br /> P�perty Owner Name: (ryA✓✓P rT �cl��M(rY� j <br /> InstallaHon Address: J 7�Z tQ/bU �v-� �' <br /> Clry: EVPrf � State: (�� Zip: 9r��D/ I <br /> Mailing Address(1/uiHerenq: 1�863 6Pc/�YPP�c Y�wy �/GSf �', <br /> City: �Q�/h oYt � Slate: �it/� Zlp: 9g� Z <br /> Email: �1`1kII�q��t�6N'�qy�•lO�r Phone: (�/L�2�1(0?°70 <br /> � � <br /> Totai Cast to Inslall�evice(hom conlydclorinvaice):S 2y3/. ��' <br /> I, the property ovmer,request to have lhe Cily of Everetl Backwater Prevention Device rehate check <br /> for the inslal�alion of the device at tho above referonced property address be made payable to,and <br /> sent lo,the vendor specified on lbe back of lhis lorm Eiy requesUng the rebale check be mado � <br /> payabte to Ihe vendor,I agree lo the follawing, <br /> 1 I will not receive a rebate check directly trom the City of EvereK � <br /> 2. Assigning paymenl of lhe rebale to the vendor does nol exempl me(rom Backwaler <br /> Prevention Device Rebale Piogram requiremenls. <br /> I �ulhodze Ihe release of my rebale lo Iha vendor lisled on Ihe back of lhis(orm pending <br /> approval of the completed Backwater Prevenlion Oevice rebale packet by lhe City of EvereR <br /> i <br /> � <br /> _._ � // /.S— <br /> Sign re of Property Owner Dale � <br /> i <br />