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i <br /> � <br /> Backwater Prevention Device ' <br /> Rebate Program ; <br /> � <br /> � <br /> � <br /> For internal Use: Project Number: � <br /> I <br /> Vendor Payment Option Form { <br /> ; <br /> Pleasa complete both sides of the form ! <br /> � <br /> Property Owner Section (please print): � <br /> -- �---- � <br /> i <br /> ��;� Lolaf� bn►,c, � <br /> , <br /> Property Owner Name i <br /> t ��,�i E��rr P�.�i ���.t.�'7 �...� �t�2� � <br /> Property Address City State Zip � <br /> �� VE�'nov� � _ �+c. 5{evGL�.4 wQ- g871� � <br /> AUemate Maiting Address City State Zlp t <br /> 2ob- 7 ,0— 5 Z �e.viN l.e�n►+� � � <br /> �l � �a.nA�RR�wr a� �.—T n� i <br /> Phone Email i <br /> t <br /> f <br /> I, the Property Owner, request to have the City of Everett Backwater Prevention Device ! <br /> rebate check for the installation referenced at the Property Address be made payable � <br /> to, and sent to, the Vendor. By requesting lhe incentive/rebate check be made payable � <br /> to the Vendor, I �gree to the following: <br /> 1. I will not receive a Backwater Prevention Devlce rebate check directly fror,t the j <br /> City of Everett. ! <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br /> does not exempl me from Backwator Preventlon Uevice R4bate Program ' <br /> requiremenls. � <br /> i <br /> . � <br /> I authorize the release o(my rebale io the Vondor listed on page two of this form ; <br /> pending approval of the completed Back�vater Prevenlion Device rebate package by � <br /> ihe City of Everett � <br /> � <br /> � <br /> i <br /> (� �� S /,� f <br /> Signafurt:ol Property Owner Dafe � <br /> � <br /> � <br /> I <br /> � <br /> � <br /> Pac�e 1 of 2 ' <br /> Rovised 8/3/2014 <br /> t <br /> � <br />