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�Backwater Prevention Devic+a Rebate Program <br /> Vendor PaymF;nt Option Form <br /> �'"" <br /> Projact Num6or. (City�o Provlde) <br /> Please compiste bott� sldes of the torm <br /> Property Ovmer 3ection: <br /> Property O�v�er Name: k J�� !U��' tti' -� 1 F. .S 1. � � r�, ;'1 !vo(' <br /> , ,_ <br /> InalalleHor Addresa:� � °-� � �' � �� �'` �� <br /> C�,, =�-•J'•'-'..��' Slet�: �✓�c�� ZP. -�t %s' c= ` <br /> Malllreg Address(I/ddfererrfJ: <br /> City: Stete: Zlp: <br /> � wp �.5.. ` S.L ?; -;c� <br /> Email: � �v� �,n..�! , � Cc�yx_w5�• �. Phorre:( ) I <br /> 7otei Cost to insfall Devlce(from 000tradaMvolce):5� L1 � � ' � � <br /> i,the properry ownw,requeet to hevo Ihe Clty of Everea Backwetx P�sventton Oavtce rebate chedc <br /> tor the Instellatlon of the device at the above reterenced properry eddress be mado payablo lo,end <br /> Aent to,lhe vondor spedted on the back of tl+lc fo�m.By requesting the rebale check be mado <br /> paysbla to the vendor, I agreo to tha Tollowirtg: <br /> 1. I wAI not rece�ve a robsie cAeck dlrecty fmm the Clty of Everetl. <br /> 2. Aasigning pay�nenl oi tha rebate lo tt!o vendor does nat axempt me imm Backwnter <br /> Prevencon Devlca Robale Program reQuirements. <br /> . � -_�`.` <br /> I euthoHzo ihe release of my iebato to Ihe vendor Ilsted on lho badc ot Mis fortn p�#eb <br /> approval of tha completad 9ackweter Preventlon Device reba!e packet by Ihe City of Everett <br /> � ' . <br /> � �� + � <br /> ��? (;������._.___ x �-z �- ,;- <br /> r <br /> Slgnature of Property Owner Dete <br />