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� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />For internal Usc: Projecl Number: <br />Ve�ndor I�ayr�ent Option Form <br />Pleasr. complete both sides of the form <br />Property Owner S�ction (please print): <br />-l_`_: ° 11 � V1 G'�/�__ - <br />Owner Name � , .-----'— <br />Address <br />Alt.emale Maihng Address <br />City � / h State <br />N/! , <br />Cily State �i� <br />� Nhone.�3 L5'-; J�I`3��16 Frrail `i"'� �1. ,r <br />� ��_� <br />Li� M <br />i, the Properly Owner, request lo have the City of Everett B,eckwater Prevention Device <br />rehafe check (or the installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesling the incentive/reUate check be made payable <br />to thei Vendor, I agree to the following: <br />1. I will not receive a Har.kvdater Prevention Device rebate check directly (rom Ihe <br />City of f_verett. <br />?. Assigniny payment of the Backwater Prevention Device rebate to the Vendor <br />does not exempt me (rom E3ackvdater {'reventinn �evice Rebato Program <br />requirements. <br />I.authorize: ihe release o( my rebatr. lo ihe Vendor listed on page two ot this forrn <br />pending approval nl tlie compleleid (3�ckwaler Prnvenlion Device rebale package by <br />Ilie (:ily of Evefe;{(� <br />�-- ,� --- <br />P�operly O�vner <br />Revisr�d; 9131201 q <br />�-�-15_ <br />Dafo <br />f'�gr. 1 of 2 <br />