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� Backwater Fr•eyention Device:Rebate Program. <br /> 1/endor Payment Option fo.rm <br /> Project Numher. _ _____ (C�'y fo Provide) <br /> Please can�ple2e bothsides of the form <br /> Property Owner Section: <br /> I Property O�vner Namet __ �� � �e0.��- - — - - <br /> �- — . <br /> Installation Address: �l� �9�'�`^� ��� <br /> C„ityr ��.-V-eYZ-�____.Stafz: _lnl� Zip: QU7�� � _ <br /> :Mailing.Addre:g(if.di/(erent): .-- ��"�`^'Z- <br /> ' �'C�Y':-_ Slate: .Zip:_— <br /> � o.�f 1'Jlil� �L �'S <�',r�u��f� , cCr�'1 y"� 8 � <br /> Email: � ._�_ `�-- _--- -- - Pltone• ( ° )_[. �f_s`3 30 _ <br /> • ' Total'Cost(o Instali Device((r�rit contnctor,invoiceJ &_ Z yI�I '��� 1'^�• ��� <br /> I,fhe ptoperly.o�.vn�r recjuesCt�ha}�e tfie Cily ul Everett Bac'r.waler,Prevention Deyice rebat^•cheek <br /> foc tfiz installatinn of the cievii;e at ll�e.a6ove ro(erance� property address be,m�de payable to, and , <br /> : se�it;l�, the vendor �pecifieh on the'bar,F;of lhis.(onn.Fiy retjuesling'th� re4af� check be,made ' <br /> payablaio thc vandoc, I agree to ttie'folloa:ing . <br /> �v' 1. I tvilFnot.reo�ii�e i n:hatc cfieck,diiectly.Gom llie City of Evereti. <br /> �j2. Assiqning piiymenLr�Lthe rebate to.the.vencior docs nol exem}�Pme.(mni�Back�4ater • <br /> . ',PFeveqtion qevice ReujtdNiogram reyuirernents. <br /> I I +ulhonz�tfie rrle� e o(my rqtiale �o the vendqr•litile;d nnihe t�ack of.this torm pending, � ! <br /> ���proval;o(the c ompl��ter�BackwaterPre�en(iqn.Devir� ietiale packef by tlie.Cily�pf Everr.ft . <br /> • ,,•,�• . . , <br /> `� �� /�Cc'� l Zb /�r <br /> =- � �� - . <br /> Signature o(Property'Oc�ner p��� J � <br /> , . - . . • -- --�J ' <br /> ' t � . ' �. " . .. � i. •. .. � . . � ,.- <br />