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� <br /> Backwater Prevention Device <br /> a Rebate Program <br /> For intemal Use: Project Number: <br /> Venclor Payrrient Option Form <br /> Please complete both sides of the form <br /> ProE��erty;Owner Section (please print): <br /> ���� L �v,,,z 'Cvrst�w <br /> (Prup rty Own r Name �� — <br /> ' " �Z\�3 ���id �1� ��v�� �JA l�-01 <br /> Propeity.Ad�ress ' City; 5tate: (Zi�. <br /> � <br /> Aitemate Nlaiiing Address � City . ;State� Zi�� <br /> - S�a'.- �l9-�D�.o1' -�v-o�v.nw �--1 cc�. <br /> Phcne �Email <br /> I, the Prope�ty Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate cfieck for the installation referenced at the Property Address be made payable <br /> to, and sent to, lhe Vendor. Eiy requesting the incentive/rebate check be made payable <br /> lo the Vendor, I agree to the following: <br /> 1. I vaill not receive a Ba�kwater Prevention Devir.e rebate check directly from the <br /> � City of Everett. <br /> '1_. �ssigning payment of lhe 82ckwater Prevention Device rebate to the Vendor <br /> does'not exempt me irom Dackwater Prevention Device Re6ate Program <br /> reyuirements. <br /> I authorize:�the release of my rebale to ll�e Vendor listed on page two oF this form <br /> pend,ing approval ot the completed Dackwater Prevention Device rebate packayc by <br /> the City oF Everett <br /> � ' 1! <br /> `�-- � <br /> —�� �� — <br /> 'Sie �aWro of roperfy Owncr= Date� <br /> ' �- <br /> Revisr.d 91:t/2014 �'''��� °�Z <br />